The New Gastroenterologist

Season 2 of Small Talk, Big Topics is here!

AGA’s podcast for trainees and early career GIs, Small Talk, Big Topics, is back for season two. To kick off the new season, hosts Drs. Matthew Whitson, Nina Nandy, and CS Tse sit down with AGA President Dr. John Carethers in a two-part special to chat about his career and how his involvement with AGA has impacted him.

In episode one, Drs. Whitson, Nandy and Tse take a deep dive with Dr. Carethers to reflect on how he first got involved with AGA, his experience with different committees, and how those roles paved the way to leadership positions.

Now, as president, he says, “I am having so much fun. AGA has been with me for my entire GI career. It’s really the voice of the science and practice of gastroenterology.”

In episode two, Dr. Carethers examines the career advice he’s received, how it shaped his leadership style and provides guidance to early career GIs.

“What’s important about some of these higher-level [decisions] is to set a vision. You can’t be a leader if you have no followers, and people have to believe in something, that they’re moving toward something.”

Listen to more of Dr. Carethers’ insight in the first two episodes of Small Talk, Big Topics wherever you listen to podcasts and subscribe to stay up to date on new episodes.
 

Maximize your first day at DDW^® 2023

Held during the first day of Digestive Disease Week^®, this year’s AGA Postgraduate Course will be held live on Saturday, May 6, from 8:30 a.m. to 5 p.m. CT. This year’s theme – Advances in Gastroenterology: News You Can Use – will help you cut through the noise surrounding best practices for GI physicians.

Pricing is the same for both in-person and virtual attendees, giving you the flexibility to experience the course in-person or from the comfort of your home. All registrants will have on-demand access to the course for three months and the opportunity to earn up to 17.5 total credits when you complete all on-demand content.
 

What’s new this year?

General session format
Presentations will be given in an engaging format that will feel less didactic and more akin to a discussion among faculty, or a conversation with the experts! It’s also an exciting opportunity to mix junior and senior lecturers on the same platform.

Recent clinical practices
Session panelists will work together to select the key papers in their topic areas for discussion. Only the newest — within one year — and most important papers, clinical guidelines and pathways in the field will be selected.

Register to attend DDW and the Postgraduate Course today.

And the winner of this year’s Shark Tank is …

The 13th annual AGA Tech Summit took place in San Francisco, Calif., recently, bringing together GI entrepreneurs, clinicians, medical technology companies, venture capitalists, and regulatory agencies working to improve patient care in the field. A highlight of the event is the annual Shark Tank competition, where forward-thinking companies showcase and pitch their innovations to a panel of expert judges. 

Congratulations to this year’s winner – Endiatx!
From devices providing rapid cancer detection to technology that makes endoscopy safer, the five companies selected for the 2023 AGA Shark Tank represented a glimpse of the future of GI patient care. 

While each team offered a creative solution to modern-day GI challenges, only one could be declared the winner. Congratulations to our 2023 winner, Endiatx! Endiatx will represent AGA in the upcoming Shark Tank competition at DDW^®. 
 

Endiatx has developed a vitamin-sized intrabody robot
PillBot is a miniature robotic capsule endoscopy. Shipped to a patient’s home or picked up from a pharmacy, the standard size capsule is swallowed and then controlled by an external joystick-like device or a phone app by a physician in a physically separate location. Using real-time video transmissions visible to both operator and patient, the capsule navigates the entire stomach in a few minutes without anesthesia and ultimately is excreted outside the body without the need for recapture.

Future GI physician innovators

This year the AGA Center for GI Innovation and Technology (CGIT) welcomed 22 first-year to advanced endoscopy fellows to the AGA Innovation Fellows Program. The program provides a unique opportunity for the fellows to learn from GI clinicians, innovators, entrepreneurs, and medical technology executives on how new technologies are developed and brought to market.

American Gastroenterological Association

The fellows received an exclusive behind-the-scenes tour of Medtronic’s R&D facility in Santa Clara, Calif., and got to experience hands-on demonstrations of GI Genius^TM, PillCam^TM, Endoflip^TM, Nexpowder^TM, Bravo^TM, Barrx^TM and ProdiGI^TM technologies. The group was also hosted by Boston Scientific Corporation, Castle Biosciences and PENTAX Medical at a dinner that included an innovators panel discussion. The program will continue throughout the year with monthly educational sessions moderated by members of the AGA CGIT committee. 

• Mohd Amer Alsamman, MD, Georgetown University
• Mohammad Arfeen, MD, Franciscan Health Olympia Fields
• Alexis Bayudan, MD, University of California, San Francisco
• Aileen Bui, MD, University of Southern California
• Divya Chalikonda, MD, Thomas Jefferson University Hospital
• Alec Faggen, MD, University of California, San Francisco
• Sweta Ghosh, PhD, University of Louisville School of Medicine
• Hemant Goyal, MD, University of Texas Houston
• Averill Guo, MD, Brown University
• Omar Jamil, MD, University of Chicago
• Christina Kratschmer, MD, Washington University in St. Louis
• Thi Khuc, MD, University of Maryland School of Medicine
• Anand Kumar, MD, Northwell Health – Lenox Hill Hospital
• Xing Li, MD, Massachusetts General Hospital
• Alana Persaud, MD, SUNY Downstate Medical Center
• Itegbemie Obaitan, MD, Indiana University School of Medicine
• Chethan Ramprasad, MD, University of Pennsylvania
• Abhishek Satishchandran, MD, University of Michigan
• Kevin Shah, MD, Emory University School of Medicine
• Shifa Umar, MD, University of Chicago
• Kornpong Vantanasiri, MD, Mayo Clinic Rochester
• Shaleen Vasavada, MD, Baylor College of Medicine

Highlights from social media

See what else attendees shared with #AGATech on Twitter.

The 2023 AGA Tech Summit was made possible by support from Castle Biosciences and Medtronic (Diamond Sponsors), AI Medical Services, Boston Scientific, Exact Sciences Corporation, FUJIFILM Medical Systems and Olympus Corporation (Gold Sponsors), Cook Medical Inc., and STERIS Endoscopy (Silver Sponsors), and Apollo Endosurgery and EvoEndo (Bronze Sponsors).
 

AGA takes CRC month to Capitol Hill

Participating in Colorectal Cancer Awareness Month in Washington, D.C., means one thing – taking the fight to save lives from CRC to Capitol Hill and advocating for increased access to screening and research to improve outcomes.

Austin Chiang, MD, MPH

In March, AGA joined the national advocacy organization Fight Colorectal Cancer (Fight CRC) and partners in the colorectal cancer community for events in our nation’s capital. The goal was to destigmatize talking about gut health and CRC and to collaboratively develop solutions that will improve and increase access to CRC screening.

Austin Chiang, MD, MPH

Fight CRC working lunch
Former AGA president Dr. David Lieberman and fellow AGA member and FORWARD graduate Dr. Fola May served as facilitators for the coalition of public and private leaders assembled by Fight CRC. The group is working to develop an action plan to further equitable CRC screening and lower the number of lives impacted by CRC. Among the participants were insurers, industry, federal agencies, healthcare providers, retail businesses, and patients.

White House Cancer Moonshot colorectal cancer forum
In partnership with President Biden’s reignited Cancer Moonshot initiative, we joined Fight CRC and other advocacy and industry leaders in the colorectal cancer community for the Cancer Moonshot Colorectal Cancer Forum, hosted by the White House.

Dr. May participated as a panelist during the forum and discussed how we should address disparities in CRC. “Research dollars are essential in [combating CRC inequity]. We do not know how to effectively deliver care and preventive services to these populations unless we do deep dives into these particular settings to understand how to best deliver that care. This is not a “pick a model and apply broadly” approach. We need to go to the people, and we need to go to the people with the methods that work for that particular setting, and that’s going to be different in every community.”

American Gastroenterological Association

Fight CRC United in Blue rally on the National Mall
It’s become an annual tradition for us to join Fight CRC’s United in Blue rally and blue flag installation on the National Mall, and this year was no different. We joined industry and patient advocacy groups in the CRC community to raise our voices about the need for screening, research, and advocacy to improve colon cancer outcomes.

The rally included inspiring calls to action and CRC testimonials from individuals who have been personally impacted by the disease, including Rep. Donald Payne Jr. (D-NJ), who lost his father to CRC and who personally underwent screening, which led to the discovery of 13 polyps.

Dr. Manish Singla from Capital Digestive Care spoke on behalf of AGA and provided encouragement and a reminder for patients and providers.

“What I keep hearing here is patients feel like they’re not being heard – so we’re listening. We’re trying and we’re here to fight the disease with you all. Everyone here knows somebody who is due for a colonoscopy and isn’t getting it, so use your persuasion – talk about it, convince, cajole, shame – use whatever you need so that everyone gets the screenings they need,” Dr. Singla said.

Our work is just beginning: Let’s work together to encourage screenings for colorectal cancer and save lives. Join us as we remind everyone that 45 is the new 50.

Season 2 of Small Talk, Big Topics is here!

AGA’s podcast for trainees and early career GIs, Small Talk, Big Topics, is back for season two. To kick off the new season, hosts Drs. Matthew Whitson, Nina Nandy, and CS Tse sit down with AGA President Dr. John Carethers in a two-part special to chat about his career and how his involvement with AGA has impacted him.

In episode one, Drs. Whitson, Nandy and Tse take a deep dive with Dr. Carethers to reflect on how he first got involved with AGA, his experience with different committees, and how those roles paved the way to leadership positions.

Now, as president, he says, “I am having so much fun. AGA has been with me for my entire GI career. It’s really the voice of the science and practice of gastroenterology.”

In episode two, Dr. Carethers examines the career advice he’s received, how it shaped his leadership style and provides guidance to early career GIs.

“What’s important about some of these higher-level [decisions] is to set a vision. You can’t be a leader if you have no followers, and people have to believe in something, that they’re moving toward something.”

Listen to more of Dr. Carethers’ insight in the first two episodes of Small Talk, Big Topics wherever you listen to podcasts and subscribe to stay up to date on new episodes.
 

Maximize your first day at DDW^® 2023

Held during the first day of Digestive Disease Week^®, this year’s AGA Postgraduate Course will be held live on Saturday, May 6, from 8:30 a.m. to 5 p.m. CT. This year’s theme – Advances in Gastroenterology: News You Can Use – will help you cut through the noise surrounding best practices for GI physicians.

Pricing is the same for both in-person and virtual attendees, giving you the flexibility to experience the course in-person or from the comfort of your home. All registrants will have on-demand access to the course for three months and the opportunity to earn up to 17.5 total credits when you complete all on-demand content.
 

What’s new this year?

General session format
Presentations will be given in an engaging format that will feel less didactic and more akin to a discussion among faculty, or a conversation with the experts! It’s also an exciting opportunity to mix junior and senior lecturers on the same platform.

Recent clinical practices
Session panelists will work together to select the key papers in their topic areas for discussion. Only the newest — within one year — and most important papers, clinical guidelines and pathways in the field will be selected.

Register to attend DDW and the Postgraduate Course today.

And the winner of this year’s Shark Tank is …

The 13th annual AGA Tech Summit took place in San Francisco, Calif., recently, bringing together GI entrepreneurs, clinicians, medical technology companies, venture capitalists, and regulatory agencies working to improve patient care in the field. A highlight of the event is the annual Shark Tank competition, where forward-thinking companies showcase and pitch their innovations to a panel of expert judges. 

Congratulations to this year’s winner – Endiatx!
From devices providing rapid cancer detection to technology that makes endoscopy safer, the five companies selected for the 2023 AGA Shark Tank represented a glimpse of the future of GI patient care. 

While each team offered a creative solution to modern-day GI challenges, only one could be declared the winner. Congratulations to our 2023 winner, Endiatx! Endiatx will represent AGA in the upcoming Shark Tank competition at DDW^®. 
 

Endiatx has developed a vitamin-sized intrabody robot
PillBot is a miniature robotic capsule endoscopy. Shipped to a patient’s home or picked up from a pharmacy, the standard size capsule is swallowed and then controlled by an external joystick-like device or a phone app by a physician in a physically separate location. Using real-time video transmissions visible to both operator and patient, the capsule navigates the entire stomach in a few minutes without anesthesia and ultimately is excreted outside the body without the need for recapture.

Future GI physician innovators

This year the AGA Center for GI Innovation and Technology (CGIT) welcomed 22 first-year to advanced endoscopy fellows to the AGA Innovation Fellows Program. The program provides a unique opportunity for the fellows to learn from GI clinicians, innovators, entrepreneurs, and medical technology executives on how new technologies are developed and brought to market.

American Gastroenterological Association

The fellows received an exclusive behind-the-scenes tour of Medtronic’s R&D facility in Santa Clara, Calif., and got to experience hands-on demonstrations of GI Genius^TM, PillCam^TM, Endoflip^TM, Nexpowder^TM, Bravo^TM, Barrx^TM and ProdiGI^TM technologies. The group was also hosted by Boston Scientific Corporation, Castle Biosciences and PENTAX Medical at a dinner that included an innovators panel discussion. The program will continue throughout the year with monthly educational sessions moderated by members of the AGA CGIT committee. 

• Mohd Amer Alsamman, MD, Georgetown University
• Mohammad Arfeen, MD, Franciscan Health Olympia Fields
• Alexis Bayudan, MD, University of California, San Francisco
• Aileen Bui, MD, University of Southern California
• Divya Chalikonda, MD, Thomas Jefferson University Hospital
• Alec Faggen, MD, University of California, San Francisco
• Sweta Ghosh, PhD, University of Louisville School of Medicine
• Hemant Goyal, MD, University of Texas Houston
• Averill Guo, MD, Brown University
• Omar Jamil, MD, University of Chicago
• Christina Kratschmer, MD, Washington University in St. Louis
• Thi Khuc, MD, University of Maryland School of Medicine
• Anand Kumar, MD, Northwell Health – Lenox Hill Hospital
• Xing Li, MD, Massachusetts General Hospital
• Alana Persaud, MD, SUNY Downstate Medical Center
• Itegbemie Obaitan, MD, Indiana University School of Medicine
• Chethan Ramprasad, MD, University of Pennsylvania
• Abhishek Satishchandran, MD, University of Michigan
• Kevin Shah, MD, Emory University School of Medicine
• Shifa Umar, MD, University of Chicago
• Kornpong Vantanasiri, MD, Mayo Clinic Rochester
• Shaleen Vasavada, MD, Baylor College of Medicine

Highlights from social media

See what else attendees shared with #AGATech on Twitter.

The 2023 AGA Tech Summit was made possible by support from Castle Biosciences and Medtronic (Diamond Sponsors), AI Medical Services, Boston Scientific, Exact Sciences Corporation, FUJIFILM Medical Systems and Olympus Corporation (Gold Sponsors), Cook Medical Inc., and STERIS Endoscopy (Silver Sponsors), and Apollo Endosurgery and EvoEndo (Bronze Sponsors).
 

AGA takes CRC month to Capitol Hill

Participating in Colorectal Cancer Awareness Month in Washington, D.C., means one thing – taking the fight to save lives from CRC to Capitol Hill and advocating for increased access to screening and research to improve outcomes.

Austin Chiang, MD, MPH

In March, AGA joined the national advocacy organization Fight Colorectal Cancer (Fight CRC) and partners in the colorectal cancer community for events in our nation’s capital. The goal was to destigmatize talking about gut health and CRC and to collaboratively develop solutions that will improve and increase access to CRC screening.

Austin Chiang, MD, MPH

Fight CRC working lunch
Former AGA president Dr. David Lieberman and fellow AGA member and FORWARD graduate Dr. Fola May served as facilitators for the coalition of public and private leaders assembled by Fight CRC. The group is working to develop an action plan to further equitable CRC screening and lower the number of lives impacted by CRC. Among the participants were insurers, industry, federal agencies, healthcare providers, retail businesses, and patients.

White House Cancer Moonshot colorectal cancer forum
In partnership with President Biden’s reignited Cancer Moonshot initiative, we joined Fight CRC and other advocacy and industry leaders in the colorectal cancer community for the Cancer Moonshot Colorectal Cancer Forum, hosted by the White House.

Dr. May participated as a panelist during the forum and discussed how we should address disparities in CRC. “Research dollars are essential in [combating CRC inequity]. We do not know how to effectively deliver care and preventive services to these populations unless we do deep dives into these particular settings to understand how to best deliver that care. This is not a “pick a model and apply broadly” approach. We need to go to the people, and we need to go to the people with the methods that work for that particular setting, and that’s going to be different in every community.”

American Gastroenterological Association

Fight CRC United in Blue rally on the National Mall
It’s become an annual tradition for us to join Fight CRC’s United in Blue rally and blue flag installation on the National Mall, and this year was no different. We joined industry and patient advocacy groups in the CRC community to raise our voices about the need for screening, research, and advocacy to improve colon cancer outcomes.

The rally included inspiring calls to action and CRC testimonials from individuals who have been personally impacted by the disease, including Rep. Donald Payne Jr. (D-NJ), who lost his father to CRC and who personally underwent screening, which led to the discovery of 13 polyps.

Dr. Manish Singla from Capital Digestive Care spoke on behalf of AGA and provided encouragement and a reminder for patients and providers.

“What I keep hearing here is patients feel like they’re not being heard – so we’re listening. We’re trying and we’re here to fight the disease with you all. Everyone here knows somebody who is due for a colonoscopy and isn’t getting it, so use your persuasion – talk about it, convince, cajole, shame – use whatever you need so that everyone gets the screenings they need,” Dr. Singla said.

Our work is just beginning: Let’s work together to encourage screenings for colorectal cancer and save lives. Join us as we remind everyone that 45 is the new 50.

Season 2 of Small Talk, Big Topics is here!

AGA’s podcast for trainees and early career GIs, Small Talk, Big Topics, is back for season two. To kick off the new season, hosts Drs. Matthew Whitson, Nina Nandy, and CS Tse sit down with AGA President Dr. John Carethers in a two-part special to chat about his career and how his involvement with AGA has impacted him.

In episode one, Drs. Whitson, Nandy and Tse take a deep dive with Dr. Carethers to reflect on how he first got involved with AGA, his experience with different committees, and how those roles paved the way to leadership positions.

Now, as president, he says, “I am having so much fun. AGA has been with me for my entire GI career. It’s really the voice of the science and practice of gastroenterology.”

In episode two, Dr. Carethers examines the career advice he’s received, how it shaped his leadership style and provides guidance to early career GIs.

“What’s important about some of these higher-level [decisions] is to set a vision. You can’t be a leader if you have no followers, and people have to believe in something, that they’re moving toward something.”

Listen to more of Dr. Carethers’ insight in the first two episodes of Small Talk, Big Topics wherever you listen to podcasts and subscribe to stay up to date on new episodes.
 

Maximize your first day at DDW^® 2023

Held during the first day of Digestive Disease Week^®, this year’s AGA Postgraduate Course will be held live on Saturday, May 6, from 8:30 a.m. to 5 p.m. CT. This year’s theme – Advances in Gastroenterology: News You Can Use – will help you cut through the noise surrounding best practices for GI physicians.

Pricing is the same for both in-person and virtual attendees, giving you the flexibility to experience the course in-person or from the comfort of your home. All registrants will have on-demand access to the course for three months and the opportunity to earn up to 17.5 total credits when you complete all on-demand content.
 

What’s new this year?

General session format
Presentations will be given in an engaging format that will feel less didactic and more akin to a discussion among faculty, or a conversation with the experts! It’s also an exciting opportunity to mix junior and senior lecturers on the same platform.

Recent clinical practices
Session panelists will work together to select the key papers in their topic areas for discussion. Only the newest — within one year — and most important papers, clinical guidelines and pathways in the field will be selected.

Register to attend DDW and the Postgraduate Course today.

And the winner of this year’s Shark Tank is …

The 13th annual AGA Tech Summit took place in San Francisco, Calif., recently, bringing together GI entrepreneurs, clinicians, medical technology companies, venture capitalists, and regulatory agencies working to improve patient care in the field. A highlight of the event is the annual Shark Tank competition, where forward-thinking companies showcase and pitch their innovations to a panel of expert judges. 

Congratulations to this year’s winner – Endiatx!
From devices providing rapid cancer detection to technology that makes endoscopy safer, the five companies selected for the 2023 AGA Shark Tank represented a glimpse of the future of GI patient care. 

While each team offered a creative solution to modern-day GI challenges, only one could be declared the winner. Congratulations to our 2023 winner, Endiatx! Endiatx will represent AGA in the upcoming Shark Tank competition at DDW^®. 
 

Endiatx has developed a vitamin-sized intrabody robot
PillBot is a miniature robotic capsule endoscopy. Shipped to a patient’s home or picked up from a pharmacy, the standard size capsule is swallowed and then controlled by an external joystick-like device or a phone app by a physician in a physically separate location. Using real-time video transmissions visible to both operator and patient, the capsule navigates the entire stomach in a few minutes without anesthesia and ultimately is excreted outside the body without the need for recapture.

Future GI physician innovators

This year the AGA Center for GI Innovation and Technology (CGIT) welcomed 22 first-year to advanced endoscopy fellows to the AGA Innovation Fellows Program. The program provides a unique opportunity for the fellows to learn from GI clinicians, innovators, entrepreneurs, and medical technology executives on how new technologies are developed and brought to market.

American Gastroenterological Association

The fellows received an exclusive behind-the-scenes tour of Medtronic’s R&D facility in Santa Clara, Calif., and got to experience hands-on demonstrations of GI Genius^TM, PillCam^TM, Endoflip^TM, Nexpowder^TM, Bravo^TM, Barrx^TM and ProdiGI^TM technologies. The group was also hosted by Boston Scientific Corporation, Castle Biosciences and PENTAX Medical at a dinner that included an innovators panel discussion. The program will continue throughout the year with monthly educational sessions moderated by members of the AGA CGIT committee. 

• Mohd Amer Alsamman, MD, Georgetown University
• Mohammad Arfeen, MD, Franciscan Health Olympia Fields
• Alexis Bayudan, MD, University of California, San Francisco
• Aileen Bui, MD, University of Southern California
• Divya Chalikonda, MD, Thomas Jefferson University Hospital
• Alec Faggen, MD, University of California, San Francisco
• Sweta Ghosh, PhD, University of Louisville School of Medicine
• Hemant Goyal, MD, University of Texas Houston
• Averill Guo, MD, Brown University
• Omar Jamil, MD, University of Chicago
• Christina Kratschmer, MD, Washington University in St. Louis
• Thi Khuc, MD, University of Maryland School of Medicine
• Anand Kumar, MD, Northwell Health – Lenox Hill Hospital
• Xing Li, MD, Massachusetts General Hospital
• Alana Persaud, MD, SUNY Downstate Medical Center
• Itegbemie Obaitan, MD, Indiana University School of Medicine
• Chethan Ramprasad, MD, University of Pennsylvania
• Abhishek Satishchandran, MD, University of Michigan
• Kevin Shah, MD, Emory University School of Medicine
• Shifa Umar, MD, University of Chicago
• Kornpong Vantanasiri, MD, Mayo Clinic Rochester
• Shaleen Vasavada, MD, Baylor College of Medicine

Highlights from social media

See what else attendees shared with #AGATech on Twitter.

The 2023 AGA Tech Summit was made possible by support from Castle Biosciences and Medtronic (Diamond Sponsors), AI Medical Services, Boston Scientific, Exact Sciences Corporation, FUJIFILM Medical Systems and Olympus Corporation (Gold Sponsors), Cook Medical Inc., and STERIS Endoscopy (Silver Sponsors), and Apollo Endosurgery and EvoEndo (Bronze Sponsors).
 

AGA takes CRC month to Capitol Hill

Participating in Colorectal Cancer Awareness Month in Washington, D.C., means one thing – taking the fight to save lives from CRC to Capitol Hill and advocating for increased access to screening and research to improve outcomes.

Austin Chiang, MD, MPH

In March, AGA joined the national advocacy organization Fight Colorectal Cancer (Fight CRC) and partners in the colorectal cancer community for events in our nation’s capital. The goal was to destigmatize talking about gut health and CRC and to collaboratively develop solutions that will improve and increase access to CRC screening.

Austin Chiang, MD, MPH

Fight CRC working lunch
Former AGA president Dr. David Lieberman and fellow AGA member and FORWARD graduate Dr. Fola May served as facilitators for the coalition of public and private leaders assembled by Fight CRC. The group is working to develop an action plan to further equitable CRC screening and lower the number of lives impacted by CRC. Among the participants were insurers, industry, federal agencies, healthcare providers, retail businesses, and patients.

White House Cancer Moonshot colorectal cancer forum
In partnership with President Biden’s reignited Cancer Moonshot initiative, we joined Fight CRC and other advocacy and industry leaders in the colorectal cancer community for the Cancer Moonshot Colorectal Cancer Forum, hosted by the White House.

Dr. May participated as a panelist during the forum and discussed how we should address disparities in CRC. “Research dollars are essential in [combating CRC inequity]. We do not know how to effectively deliver care and preventive services to these populations unless we do deep dives into these particular settings to understand how to best deliver that care. This is not a “pick a model and apply broadly” approach. We need to go to the people, and we need to go to the people with the methods that work for that particular setting, and that’s going to be different in every community.”

American Gastroenterological Association

Fight CRC United in Blue rally on the National Mall
It’s become an annual tradition for us to join Fight CRC’s United in Blue rally and blue flag installation on the National Mall, and this year was no different. We joined industry and patient advocacy groups in the CRC community to raise our voices about the need for screening, research, and advocacy to improve colon cancer outcomes.

The rally included inspiring calls to action and CRC testimonials from individuals who have been personally impacted by the disease, including Rep. Donald Payne Jr. (D-NJ), who lost his father to CRC and who personally underwent screening, which led to the discovery of 13 polyps.

Dr. Manish Singla from Capital Digestive Care spoke on behalf of AGA and provided encouragement and a reminder for patients and providers.

“What I keep hearing here is patients feel like they’re not being heard – so we’re listening. We’re trying and we’re here to fight the disease with you all. Everyone here knows somebody who is due for a colonoscopy and isn’t getting it, so use your persuasion – talk about it, convince, cajole, shame – use whatever you need so that everyone gets the screenings they need,” Dr. Singla said.

Our work is just beginning: Let’s work together to encourage screenings for colorectal cancer and save lives. Join us as we remind everyone that 45 is the new 50.

Establishing an advanced endoscopy practice can appear challenging and overwhelming. It is often the culmination of more than a decade of education and training for advanced endoscopists and is usually their first foray into employment. Taking a practical, step-wise approach to establish a practice can optimize the chances of a successful transition, all while creating a rewarding opportunity to provide a population with necessary services, which, more than likely, were not previously being offered at your institution or in your region.

Tip 1: Understand the current landscape

When joining a hospital-employed or private practice, it is important for the advanced endoscopist to gauge the current landscape of the job, beginning with gaining an understanding of the current services provided by your gastroenterology colleagues. This includes knowing the types of advanced endoscopy services previously provided, especially if you have partners or colleagues who perform these procedures, and their prior referral patterns, either within or outside their respective group. Also, it is important to understand the services that are provided locally at other institutions. This will allow you to develop a niche of the types of services you can provide that are not available in the current practice set-up.

Tip 2: Connect with peers, interspecialty collaborators, and referring physicians

It is important that you connect with your GI colleagues once you start a new job. This can differ in ease depending on the size of your group. For example, in a small group, it may be easier to familiarize yourself with your colleagues through regular interactions. If you are a part of a larger practice, however, it is necessary to be more proactive and set up introductory meetings/sessions. These interactions provide a great opportunity to share your goals and start building a relationship.

Efforts also should be made to reach out to primary care, hematology/oncology, surgical/radiation oncology, general surgery, and interventional radiology physicians, as these are the specialists with whom an advanced endoscopist typically has the most interaction. The relationship with these colleagues is bidirectional, as the majority of our patients need multidisciplinary decision-making and care. For example, the first time you speak to the colorectal surgeon at your institution should not be in the middle of a complication. The purpose of these introductions should not be solely to inform them of the services you are offering but to start developing a relationship in a true sense, because eventually those relationships will transform into excellent patient care.

Tip 3: Communication

Communication is a key principle in building a practice. Referring physicians often entrust you with managing a part of their patient’s medical problems. Patient/procedure outcomes should be relayed promptly to referring physicians, as this not only helps build the trust of the referring physician, but also enhances the patient’s trust in the health system, knowing that all physicians are communicating with the common goal of improving the patient’s disease course.

Communication with the referring physician is important not only after a procedure but also before it. Know that a consult is an “ask for help.” For example, even if you are not the correct specialist for a referral (for example, an inflammatory bowel disease patient was sent to an advanced endoscopist), it is good practice to take ownership of the patient and forward that person to the appropriate colleague.
 

Tip 4: Build a local reputation

Building upon this, it is also important to connect with other GI groups in the community, regardless of whether they have their own affiliated advanced endoscopists. This helps determine the advanced endoscopy services being offered regionally, which will further allow an understanding of the unmet needs of the region. In addition, building a relationship with local advanced endoscopists in the region can help establish a collaborative relationship going forward, rather than a contentious/competitive dynamic.

Tip 5: Advance your skills

As advanced endoscopy fellows are aware, completing an advanced endoscopy fellowship allows for building a strong foundation of skills, which will continue to refine and grow as you advance in your career.

Depending on your skill-set and training, the first year should focus on developing and establishing “your style” (since the training is tailored to follow the practice patterns of your mentors). The first few months are good to focus on refining endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, endoscopic mucosal resection, and luminal stenting techniques. As you start to build a reputation of being “safe, thoughtful, and skilled” and depending on your interests and goals, continued engagement in the advanced endoscopy community to understand new technologies/procedures is helpful. It is important to remember that new skills and procedures can be introduced in your practice, but this should be done in a timely and patient manner. You should appropriately educate and train yourself for such procedures through educational conferences/courses, shadowing and routine engagement with mentors, and collaboration with industry partners.
 

Tip 6: Team building

From a procedural standpoint, certain staff members should be recognized to be part of or lead an “advanced endoscopy team,” with a goal of dedicated exposure to a high volume of complex procedures. This builds camaraderie and trust within the team of advanced endoscopy nurses and technicians going forward, which is crucial to introducing and building a high-complexity procedural service. This is also an excellent opportunity to partner with our industry colleagues to ensure that they can train your team on the use of novel devices.

Tip 7: Offering new services to your patients

Advanced endoscopy is a rapidly evolving specialty, and new procedures, technology, and devices are allowing us to provide minimally invasive options to our patients. It is important that prior to introducing new services and programs, your hospital/practice administration should be informed about any such plans. Also, all potential collaborating services (surgery, interventional radiology, etc.) should be part of the decision-making to ensure patients receive the best possible multidisciplinary care.

Tip 8: Mentorship and peer-mentorship

Establishing a network of regional and national advanced endoscopy colleagues and mentors is critical. This may be harder to develop in community-based and private practice, where one may feel that they are on an “island.” Engagement with national organizations, use of social media, and other avenues are excellent ways to build this network. Advanced endoscopic procedures also are associated with higher rates of adverse events, so having a peer-support group to provide emotional and moral support when these adverse events occur also is important. Such a network also includes those collaborating specialties to which you would refer (surgical oncology, thoracic surgery, etc.). Being involved in local tumor boards and “gut clubs” is another way of remaining engaged and not feeling isolated.

Tip 9: Have fun

Advanced endoscopy can be busy, as well as physically and mentally exhausting. It is important to maintain a good work-life balance. In addition, planning scheduled retreats or social events with your advanced endoscopy team (nurses, technicians, schedulers, colleagues) is important not only to show appreciation, but also to help build camaraderie and develop relationships.

Tip 10: Remember your ‘why’

Often times, there can be stressors associated with building a practice and increasing your volume, therefore, it is always important to remember why you became a medical professional and advanced endoscopist. This will get you through the days where you had a complication or when things didn’t go as planned.
 

Conclusion

Lastly, it is important to keep revisiting your skill sets and practice and evaluate what is working well and what can be improved. To all the advanced endoscopists starting their careers: Be patient and have a positive attitude! The leaders in our field did not become so overnight, and an advanced endoscopy–based career resembles a marathon rather than a sprint. Mistakes during procedures and practice building can be made, but how you grow and learn from those mistakes is what determines how likely you are to succeed going forward. Respect and acknowledge your staff, your collaborating physicians, and mentors. It takes time and effort to develop an advanced endoscopy practice. Being proud of your achievements and promoting procedural and patient care advances that you have made are beneficial and encouraged. We are fortunate to be in an ever-evolving specialty, and it is an exciting time to be practicing advanced endoscopy. Good luck!

Dr. Soudagar is a gastroenterologist at Northwestern Medical Group, Lake Forest, Ill. Dr. Bilal, assistant professor of medicine at the University of Minnesota, Minneapolis, is an advanced endoscopist and gastroenterologist at Minneapolis VA Medical Center. The authors have no conflicts of interest.

Establishing an advanced endoscopy practice can appear challenging and overwhelming. It is often the culmination of more than a decade of education and training for advanced endoscopists and is usually their first foray into employment. Taking a practical, step-wise approach to establish a practice can optimize the chances of a successful transition, all while creating a rewarding opportunity to provide a population with necessary services, which, more than likely, were not previously being offered at your institution or in your region.

Tip 1: Understand the current landscape

When joining a hospital-employed or private practice, it is important for the advanced endoscopist to gauge the current landscape of the job, beginning with gaining an understanding of the current services provided by your gastroenterology colleagues. This includes knowing the types of advanced endoscopy services previously provided, especially if you have partners or colleagues who perform these procedures, and their prior referral patterns, either within or outside their respective group. Also, it is important to understand the services that are provided locally at other institutions. This will allow you to develop a niche of the types of services you can provide that are not available in the current practice set-up.

Tip 2: Connect with peers, interspecialty collaborators, and referring physicians

It is important that you connect with your GI colleagues once you start a new job. This can differ in ease depending on the size of your group. For example, in a small group, it may be easier to familiarize yourself with your colleagues through regular interactions. If you are a part of a larger practice, however, it is necessary to be more proactive and set up introductory meetings/sessions. These interactions provide a great opportunity to share your goals and start building a relationship.

Efforts also should be made to reach out to primary care, hematology/oncology, surgical/radiation oncology, general surgery, and interventional radiology physicians, as these are the specialists with whom an advanced endoscopist typically has the most interaction. The relationship with these colleagues is bidirectional, as the majority of our patients need multidisciplinary decision-making and care. For example, the first time you speak to the colorectal surgeon at your institution should not be in the middle of a complication. The purpose of these introductions should not be solely to inform them of the services you are offering but to start developing a relationship in a true sense, because eventually those relationships will transform into excellent patient care.

Tip 3: Communication

Communication is a key principle in building a practice. Referring physicians often entrust you with managing a part of their patient’s medical problems. Patient/procedure outcomes should be relayed promptly to referring physicians, as this not only helps build the trust of the referring physician, but also enhances the patient’s trust in the health system, knowing that all physicians are communicating with the common goal of improving the patient’s disease course.

Communication with the referring physician is important not only after a procedure but also before it. Know that a consult is an “ask for help.” For example, even if you are not the correct specialist for a referral (for example, an inflammatory bowel disease patient was sent to an advanced endoscopist), it is good practice to take ownership of the patient and forward that person to the appropriate colleague.
 

Tip 4: Build a local reputation

Building upon this, it is also important to connect with other GI groups in the community, regardless of whether they have their own affiliated advanced endoscopists. This helps determine the advanced endoscopy services being offered regionally, which will further allow an understanding of the unmet needs of the region. In addition, building a relationship with local advanced endoscopists in the region can help establish a collaborative relationship going forward, rather than a contentious/competitive dynamic.

Tip 5: Advance your skills

As advanced endoscopy fellows are aware, completing an advanced endoscopy fellowship allows for building a strong foundation of skills, which will continue to refine and grow as you advance in your career.

Depending on your skill-set and training, the first year should focus on developing and establishing “your style” (since the training is tailored to follow the practice patterns of your mentors). The first few months are good to focus on refining endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, endoscopic mucosal resection, and luminal stenting techniques. As you start to build a reputation of being “safe, thoughtful, and skilled” and depending on your interests and goals, continued engagement in the advanced endoscopy community to understand new technologies/procedures is helpful. It is important to remember that new skills and procedures can be introduced in your practice, but this should be done in a timely and patient manner. You should appropriately educate and train yourself for such procedures through educational conferences/courses, shadowing and routine engagement with mentors, and collaboration with industry partners.
 

Tip 6: Team building

From a procedural standpoint, certain staff members should be recognized to be part of or lead an “advanced endoscopy team,” with a goal of dedicated exposure to a high volume of complex procedures. This builds camaraderie and trust within the team of advanced endoscopy nurses and technicians going forward, which is crucial to introducing and building a high-complexity procedural service. This is also an excellent opportunity to partner with our industry colleagues to ensure that they can train your team on the use of novel devices.

Tip 7: Offering new services to your patients

Advanced endoscopy is a rapidly evolving specialty, and new procedures, technology, and devices are allowing us to provide minimally invasive options to our patients. It is important that prior to introducing new services and programs, your hospital/practice administration should be informed about any such plans. Also, all potential collaborating services (surgery, interventional radiology, etc.) should be part of the decision-making to ensure patients receive the best possible multidisciplinary care.

Tip 8: Mentorship and peer-mentorship

Establishing a network of regional and national advanced endoscopy colleagues and mentors is critical. This may be harder to develop in community-based and private practice, where one may feel that they are on an “island.” Engagement with national organizations, use of social media, and other avenues are excellent ways to build this network. Advanced endoscopic procedures also are associated with higher rates of adverse events, so having a peer-support group to provide emotional and moral support when these adverse events occur also is important. Such a network also includes those collaborating specialties to which you would refer (surgical oncology, thoracic surgery, etc.). Being involved in local tumor boards and “gut clubs” is another way of remaining engaged and not feeling isolated.

Tip 9: Have fun

Advanced endoscopy can be busy, as well as physically and mentally exhausting. It is important to maintain a good work-life balance. In addition, planning scheduled retreats or social events with your advanced endoscopy team (nurses, technicians, schedulers, colleagues) is important not only to show appreciation, but also to help build camaraderie and develop relationships.

Tip 10: Remember your ‘why’

Often times, there can be stressors associated with building a practice and increasing your volume, therefore, it is always important to remember why you became a medical professional and advanced endoscopist. This will get you through the days where you had a complication or when things didn’t go as planned.
 

Conclusion

Lastly, it is important to keep revisiting your skill sets and practice and evaluate what is working well and what can be improved. To all the advanced endoscopists starting their careers: Be patient and have a positive attitude! The leaders in our field did not become so overnight, and an advanced endoscopy–based career resembles a marathon rather than a sprint. Mistakes during procedures and practice building can be made, but how you grow and learn from those mistakes is what determines how likely you are to succeed going forward. Respect and acknowledge your staff, your collaborating physicians, and mentors. It takes time and effort to develop an advanced endoscopy practice. Being proud of your achievements and promoting procedural and patient care advances that you have made are beneficial and encouraged. We are fortunate to be in an ever-evolving specialty, and it is an exciting time to be practicing advanced endoscopy. Good luck!

Dr. Soudagar is a gastroenterologist at Northwestern Medical Group, Lake Forest, Ill. Dr. Bilal, assistant professor of medicine at the University of Minnesota, Minneapolis, is an advanced endoscopist and gastroenterologist at Minneapolis VA Medical Center. The authors have no conflicts of interest.

Establishing an advanced endoscopy practice can appear challenging and overwhelming. It is often the culmination of more than a decade of education and training for advanced endoscopists and is usually their first foray into employment. Taking a practical, step-wise approach to establish a practice can optimize the chances of a successful transition, all while creating a rewarding opportunity to provide a population with necessary services, which, more than likely, were not previously being offered at your institution or in your region.

Tip 1: Understand the current landscape

When joining a hospital-employed or private practice, it is important for the advanced endoscopist to gauge the current landscape of the job, beginning with gaining an understanding of the current services provided by your gastroenterology colleagues. This includes knowing the types of advanced endoscopy services previously provided, especially if you have partners or colleagues who perform these procedures, and their prior referral patterns, either within or outside their respective group. Also, it is important to understand the services that are provided locally at other institutions. This will allow you to develop a niche of the types of services you can provide that are not available in the current practice set-up.

Tip 2: Connect with peers, interspecialty collaborators, and referring physicians

It is important that you connect with your GI colleagues once you start a new job. This can differ in ease depending on the size of your group. For example, in a small group, it may be easier to familiarize yourself with your colleagues through regular interactions. If you are a part of a larger practice, however, it is necessary to be more proactive and set up introductory meetings/sessions. These interactions provide a great opportunity to share your goals and start building a relationship.

Efforts also should be made to reach out to primary care, hematology/oncology, surgical/radiation oncology, general surgery, and interventional radiology physicians, as these are the specialists with whom an advanced endoscopist typically has the most interaction. The relationship with these colleagues is bidirectional, as the majority of our patients need multidisciplinary decision-making and care. For example, the first time you speak to the colorectal surgeon at your institution should not be in the middle of a complication. The purpose of these introductions should not be solely to inform them of the services you are offering but to start developing a relationship in a true sense, because eventually those relationships will transform into excellent patient care.

Tip 3: Communication

Communication is a key principle in building a practice. Referring physicians often entrust you with managing a part of their patient’s medical problems. Patient/procedure outcomes should be relayed promptly to referring physicians, as this not only helps build the trust of the referring physician, but also enhances the patient’s trust in the health system, knowing that all physicians are communicating with the common goal of improving the patient’s disease course.

Communication with the referring physician is important not only after a procedure but also before it. Know that a consult is an “ask for help.” For example, even if you are not the correct specialist for a referral (for example, an inflammatory bowel disease patient was sent to an advanced endoscopist), it is good practice to take ownership of the patient and forward that person to the appropriate colleague.
 

Tip 4: Build a local reputation

Building upon this, it is also important to connect with other GI groups in the community, regardless of whether they have their own affiliated advanced endoscopists. This helps determine the advanced endoscopy services being offered regionally, which will further allow an understanding of the unmet needs of the region. In addition, building a relationship with local advanced endoscopists in the region can help establish a collaborative relationship going forward, rather than a contentious/competitive dynamic.

Tip 5: Advance your skills

As advanced endoscopy fellows are aware, completing an advanced endoscopy fellowship allows for building a strong foundation of skills, which will continue to refine and grow as you advance in your career.

Depending on your skill-set and training, the first year should focus on developing and establishing “your style” (since the training is tailored to follow the practice patterns of your mentors). The first few months are good to focus on refining endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, endoscopic mucosal resection, and luminal stenting techniques. As you start to build a reputation of being “safe, thoughtful, and skilled” and depending on your interests and goals, continued engagement in the advanced endoscopy community to understand new technologies/procedures is helpful. It is important to remember that new skills and procedures can be introduced in your practice, but this should be done in a timely and patient manner. You should appropriately educate and train yourself for such procedures through educational conferences/courses, shadowing and routine engagement with mentors, and collaboration with industry partners.
 

Tip 6: Team building

From a procedural standpoint, certain staff members should be recognized to be part of or lead an “advanced endoscopy team,” with a goal of dedicated exposure to a high volume of complex procedures. This builds camaraderie and trust within the team of advanced endoscopy nurses and technicians going forward, which is crucial to introducing and building a high-complexity procedural service. This is also an excellent opportunity to partner with our industry colleagues to ensure that they can train your team on the use of novel devices.

Tip 7: Offering new services to your patients

Advanced endoscopy is a rapidly evolving specialty, and new procedures, technology, and devices are allowing us to provide minimally invasive options to our patients. It is important that prior to introducing new services and programs, your hospital/practice administration should be informed about any such plans. Also, all potential collaborating services (surgery, interventional radiology, etc.) should be part of the decision-making to ensure patients receive the best possible multidisciplinary care.

Tip 8: Mentorship and peer-mentorship

Establishing a network of regional and national advanced endoscopy colleagues and mentors is critical. This may be harder to develop in community-based and private practice, where one may feel that they are on an “island.” Engagement with national organizations, use of social media, and other avenues are excellent ways to build this network. Advanced endoscopic procedures also are associated with higher rates of adverse events, so having a peer-support group to provide emotional and moral support when these adverse events occur also is important. Such a network also includes those collaborating specialties to which you would refer (surgical oncology, thoracic surgery, etc.). Being involved in local tumor boards and “gut clubs” is another way of remaining engaged and not feeling isolated.

Tip 9: Have fun

Advanced endoscopy can be busy, as well as physically and mentally exhausting. It is important to maintain a good work-life balance. In addition, planning scheduled retreats or social events with your advanced endoscopy team (nurses, technicians, schedulers, colleagues) is important not only to show appreciation, but also to help build camaraderie and develop relationships.

Tip 10: Remember your ‘why’

Often times, there can be stressors associated with building a practice and increasing your volume, therefore, it is always important to remember why you became a medical professional and advanced endoscopist. This will get you through the days where you had a complication or when things didn’t go as planned.
 

Conclusion

Lastly, it is important to keep revisiting your skill sets and practice and evaluate what is working well and what can be improved. To all the advanced endoscopists starting their careers: Be patient and have a positive attitude! The leaders in our field did not become so overnight, and an advanced endoscopy–based career resembles a marathon rather than a sprint. Mistakes during procedures and practice building can be made, but how you grow and learn from those mistakes is what determines how likely you are to succeed going forward. Respect and acknowledge your staff, your collaborating physicians, and mentors. It takes time and effort to develop an advanced endoscopy practice. Being proud of your achievements and promoting procedural and patient care advances that you have made are beneficial and encouraged. We are fortunate to be in an ever-evolving specialty, and it is an exciting time to be practicing advanced endoscopy. Good luck!

Dr. Soudagar is a gastroenterologist at Northwestern Medical Group, Lake Forest, Ill. Dr. Bilal, assistant professor of medicine at the University of Minnesota, Minneapolis, is an advanced endoscopist and gastroenterologist at Minneapolis VA Medical Center. The authors have no conflicts of interest.

When we found out we were expecting our first child, we were ecstatic. Our excitement soon gave way to panic, however, as we realized that we needed a plan for childcare. As full-time physicians early in our careers, neither of us was prepared to drop to part-time or become a stay-at-home caregiver. Not knowing where to start, we turned to our friends and colleagues, and of course, the Internet, for advice on our options.

In our research, we discovered three things. First, with COVID-19, the cost of childcare has skyrocketed, and availability has decreased. Second, there are several options for childcare, each with its own benefits and drawbacks. Third, there is no one-size-fits-all solution. Our goal for this article is to provide an overview of the common childcare solutions and provide some practical tips to help other physicians determine what might work best for their family and situation.
 

Family

Using family members to provide childcare is often cost-effective and provides a familiar, supportive environment for children. Proximity does not guarantee a willingness or ability to provide long-term care, however, and it can cause strain on family relationships, lead to intrusions and boundary issues, and create feelings of obligation and guilt. It is important to have very honest, up-front discussions with family members about hopes and expectations if this is your childcare plan.

Daycare, facility-based

Daycare centers are commercial facilities that offer care to multiple children of varying ages, starting from as young as 6 weeks. They have trained professionals and provide structured activities and educational programs for children. Many daycares also provide snacks and lunch, which is included in their tuition. They are a popular choice for families seeking full-time childcare and the social and educational benefits that come with a structured setting.

Daycares also have some downsides. They usually operate during normal workday hours, from 7:00 a.m. to 6:00 p.m., which may not be convenient for physicians who work outside of these hours. Even with feasible hours, getting children dressed, ready, and dropped off each morning could add significant time and stress to your morning routine. Additionally, most daycares have policies that prohibit attendance if a child is sick or febrile, which is a common occurrence, particularly for daycare kids. In case of an illness outbreak, the daycare may even close for several days. Both scenarios require at least one parent to take a day off or have an alternative childcare plan available on short notice.

Availability of daycare can be limited, particularly since the COVID pandemic, creating waitlists that can be several months long. Early registration, even during pregnancy, is recommended to secure a spot. It can be helpful to find out if your employer has an agreement with a specific daycare that has “physician-friendly” hours and gives waitlist priority to trainees or even attending physicians. The cost of daycare for one child is typically affordable, around $12,000 per year on average, but can be as high as $25,000 in cities with high cost of living. A sibling discount may be offered, but the cost of daycare for multiple children could still exceed in-home childcare options.¹
 

Daycare, home-based (also known as family care centers)

Family care centers offer a home-like alternative to daycares, with smaller staff-to-child ratios and often more personalized care. They are favored by families seeking a more intimate setting. They might offer more flexible scheduling and are typically less expensive than facility-based daycares, at up to 25% lower cost.¹ They may lack the same structure and educational opportunities as facility-based daycares, however, and are not subject to the same health and safety regulations.

Nannies

Nannies are professional caregivers who provide in-home childcare services. Their responsibilities may include feeding, changing, dressing, bathing, and playing with children. In some cases, they may also be expected to do light housekeeping tasks like meal preparation, laundry, and cleaning. It is common for nannies in high-demand markets to refuse to perform these additional tasks, however. Nannies are preferred by families with hectic schedules due to their flexibility. They can work early, late, or even overnight shifts, and provide care in the comfort of your home, avoiding the hassle of drop-off and pick-up times. Nannies also can provide personalized care to meet each child’s specific needs, and they can care for children who are sick or febrile.

When hiring a nanny, it is important to have a written contract outlining their expected hours, wages, benefits, and duties to prevent misunderstandings in the future. Finding a trustworthy and reliable nanny can be a challenge, and families have several options for finding one. They can post jobs on free websites and browse nanny CVs or use a fee-based nanny agency. The cost of using an agency can range from a few hundred to several thousand dollars, so it is important to ask friends and colleagues for recommendations before paying for an agency’s services.

The cost of hiring a nanny is one of its main drawbacks. Nannies typically earn $15 to $30 per hour, and if they work in the family’s home, they are typically considered “household employees” by the IRS. Household employees are entitled to overtime pay for work beyond 40 hours per week, and the employer (you!) is responsible for payroll taxes, withholding, and providing an annual W-2 tax statement.² There are affordable online nanny payroll services that handle payroll and tax-filing to simplify the process, however. The average annual cost of a full-time nanny is around $40,000 and can be as high as $75,000 in some markets.¹ A nanny-share with other families can lower costs, but it may also result in less control over the caregiver and schedule.

It is important to consult a tax professional or the IRS for guidance on nanny wages, taxes, and payroll, as a nanny might rarely be considered an “independent contractor” if they meet certain criteria.
 

Au pair

An au pair is a live-in childcare provider who travels to a host family’s home from a foreign country on a special J-1 visa. The goal is to provide care for children and participate in cultural exchange activities. Au pairs bring many benefits, such as cost savings compared to traditional childcare options and greater flexibility and customization. They can work up to 10 hours per day and 45 hours a week, performing tasks such as light housekeeping, meal preparation, and transportation for the children. Host families must provide a safe and comfortable living environment, including a private room, meals, and some travel and education expenses.¹

The process of hiring an au pair involves working with a designated agency that matches families with applicants and sponsors the J-1 visa. The entire process can take several months, and average program fees cost around $10,000 per placement. Au pairs are hired on a 12-month J-1 visa, which can be extended for up to an additional 12 months, allowing families up to 2 years with the same au pair before needing to find a new placement.

Au pairs earn a minimum weekly stipend of $195.75, set forth by the U.S. State Department.³ Currently, au pairs are not subject to local and state wage requirements, but legal proceedings in various states have recently questioned whether au pairs should be protected under local regulations. Massachusetts has been the most progressive, explicitly protecting au pairs as domestic workers under state labor laws, raising their weekly stipend to roughly $600 to comply with state minimum wage requirements.⁴ The federal government is expected to provide clarity on this issue, but for the time being, au pairs remain an affordable alternative to a nanny in most states.
 

Conclusion

Choosing childcare is a complicated process with multiple factors to consider. Figure 1 breaks down the estimated annual cost of each of the options outlined above for a single child in low, average, and high cost-of-living areas. But your decision likely hinges on much more than just cost, and may include family dynamics, scheduling needs, and personal preferences. Gather as much advice and information as possible, but remember to trust your instincts and make the decision that works best for your family. At the end of the day, what matters most is the happiness and well-being of your child.

Dr. Hathorn and Dr. Creighton are married, and both work full-time with a 1-year-old child. Dr. Hathorn is a bariatric and advanced therapeutic endoscopist at the University of North Carolina at Chapel Hill. Dr. Creighton is an anesthesiologist at UNC Chapel Hill. Neither reported any conflicts of interest.

References

1. Care.com. This is how much childcare costs in 2022. 2022 Jun 15.

2. Internal Revenue Service. Publication 926 - Household Employer’s Tax Guide 2023.

3. U.S. Department of State. Au Pair.

4. Commonwealth of Massachusetts. Domestic workers.

Disclaimer

The financial and tax information presented in this article are believed to be true and accurate at the time of writing. However, it’s important to note that tax laws and regulations are subject to change. The authors are not certified financial advisers or tax specialists. It is recommended to seek verification from a local tax expert or the Internal Revenue Service to discuss your specific situation.

When we found out we were expecting our first child, we were ecstatic. Our excitement soon gave way to panic, however, as we realized that we needed a plan for childcare. As full-time physicians early in our careers, neither of us was prepared to drop to part-time or become a stay-at-home caregiver. Not knowing where to start, we turned to our friends and colleagues, and of course, the Internet, for advice on our options.

In our research, we discovered three things. First, with COVID-19, the cost of childcare has skyrocketed, and availability has decreased. Second, there are several options for childcare, each with its own benefits and drawbacks. Third, there is no one-size-fits-all solution. Our goal for this article is to provide an overview of the common childcare solutions and provide some practical tips to help other physicians determine what might work best for their family and situation.
 

Family

Using family members to provide childcare is often cost-effective and provides a familiar, supportive environment for children. Proximity does not guarantee a willingness or ability to provide long-term care, however, and it can cause strain on family relationships, lead to intrusions and boundary issues, and create feelings of obligation and guilt. It is important to have very honest, up-front discussions with family members about hopes and expectations if this is your childcare plan.

Daycare, facility-based

Daycare centers are commercial facilities that offer care to multiple children of varying ages, starting from as young as 6 weeks. They have trained professionals and provide structured activities and educational programs for children. Many daycares also provide snacks and lunch, which is included in their tuition. They are a popular choice for families seeking full-time childcare and the social and educational benefits that come with a structured setting.

Daycares also have some downsides. They usually operate during normal workday hours, from 7:00 a.m. to 6:00 p.m., which may not be convenient for physicians who work outside of these hours. Even with feasible hours, getting children dressed, ready, and dropped off each morning could add significant time and stress to your morning routine. Additionally, most daycares have policies that prohibit attendance if a child is sick or febrile, which is a common occurrence, particularly for daycare kids. In case of an illness outbreak, the daycare may even close for several days. Both scenarios require at least one parent to take a day off or have an alternative childcare plan available on short notice.

Availability of daycare can be limited, particularly since the COVID pandemic, creating waitlists that can be several months long. Early registration, even during pregnancy, is recommended to secure a spot. It can be helpful to find out if your employer has an agreement with a specific daycare that has “physician-friendly” hours and gives waitlist priority to trainees or even attending physicians. The cost of daycare for one child is typically affordable, around $12,000 per year on average, but can be as high as $25,000 in cities with high cost of living. A sibling discount may be offered, but the cost of daycare for multiple children could still exceed in-home childcare options.¹
 

Daycare, home-based (also known as family care centers)

Family care centers offer a home-like alternative to daycares, with smaller staff-to-child ratios and often more personalized care. They are favored by families seeking a more intimate setting. They might offer more flexible scheduling and are typically less expensive than facility-based daycares, at up to 25% lower cost.¹ They may lack the same structure and educational opportunities as facility-based daycares, however, and are not subject to the same health and safety regulations.

Nannies

Nannies are professional caregivers who provide in-home childcare services. Their responsibilities may include feeding, changing, dressing, bathing, and playing with children. In some cases, they may also be expected to do light housekeeping tasks like meal preparation, laundry, and cleaning. It is common for nannies in high-demand markets to refuse to perform these additional tasks, however. Nannies are preferred by families with hectic schedules due to their flexibility. They can work early, late, or even overnight shifts, and provide care in the comfort of your home, avoiding the hassle of drop-off and pick-up times. Nannies also can provide personalized care to meet each child’s specific needs, and they can care for children who are sick or febrile.

When hiring a nanny, it is important to have a written contract outlining their expected hours, wages, benefits, and duties to prevent misunderstandings in the future. Finding a trustworthy and reliable nanny can be a challenge, and families have several options for finding one. They can post jobs on free websites and browse nanny CVs or use a fee-based nanny agency. The cost of using an agency can range from a few hundred to several thousand dollars, so it is important to ask friends and colleagues for recommendations before paying for an agency’s services.

The cost of hiring a nanny is one of its main drawbacks. Nannies typically earn $15 to $30 per hour, and if they work in the family’s home, they are typically considered “household employees” by the IRS. Household employees are entitled to overtime pay for work beyond 40 hours per week, and the employer (you!) is responsible for payroll taxes, withholding, and providing an annual W-2 tax statement.² There are affordable online nanny payroll services that handle payroll and tax-filing to simplify the process, however. The average annual cost of a full-time nanny is around $40,000 and can be as high as $75,000 in some markets.¹ A nanny-share with other families can lower costs, but it may also result in less control over the caregiver and schedule.

It is important to consult a tax professional or the IRS for guidance on nanny wages, taxes, and payroll, as a nanny might rarely be considered an “independent contractor” if they meet certain criteria.
 

Au pair

An au pair is a live-in childcare provider who travels to a host family’s home from a foreign country on a special J-1 visa. The goal is to provide care for children and participate in cultural exchange activities. Au pairs bring many benefits, such as cost savings compared to traditional childcare options and greater flexibility and customization. They can work up to 10 hours per day and 45 hours a week, performing tasks such as light housekeeping, meal preparation, and transportation for the children. Host families must provide a safe and comfortable living environment, including a private room, meals, and some travel and education expenses.¹

The process of hiring an au pair involves working with a designated agency that matches families with applicants and sponsors the J-1 visa. The entire process can take several months, and average program fees cost around $10,000 per placement. Au pairs are hired on a 12-month J-1 visa, which can be extended for up to an additional 12 months, allowing families up to 2 years with the same au pair before needing to find a new placement.

Au pairs earn a minimum weekly stipend of $195.75, set forth by the U.S. State Department.³ Currently, au pairs are not subject to local and state wage requirements, but legal proceedings in various states have recently questioned whether au pairs should be protected under local regulations. Massachusetts has been the most progressive, explicitly protecting au pairs as domestic workers under state labor laws, raising their weekly stipend to roughly $600 to comply with state minimum wage requirements.⁴ The federal government is expected to provide clarity on this issue, but for the time being, au pairs remain an affordable alternative to a nanny in most states.
 

Conclusion

Choosing childcare is a complicated process with multiple factors to consider. Figure 1 breaks down the estimated annual cost of each of the options outlined above for a single child in low, average, and high cost-of-living areas. But your decision likely hinges on much more than just cost, and may include family dynamics, scheduling needs, and personal preferences. Gather as much advice and information as possible, but remember to trust your instincts and make the decision that works best for your family. At the end of the day, what matters most is the happiness and well-being of your child.

Dr. Hathorn and Dr. Creighton are married, and both work full-time with a 1-year-old child. Dr. Hathorn is a bariatric and advanced therapeutic endoscopist at the University of North Carolina at Chapel Hill. Dr. Creighton is an anesthesiologist at UNC Chapel Hill. Neither reported any conflicts of interest.

References

1. Care.com. This is how much childcare costs in 2022. 2022 Jun 15.

2. Internal Revenue Service. Publication 926 - Household Employer’s Tax Guide 2023.

3. U.S. Department of State. Au Pair.

4. Commonwealth of Massachusetts. Domestic workers.

Disclaimer

The financial and tax information presented in this article are believed to be true and accurate at the time of writing. However, it’s important to note that tax laws and regulations are subject to change. The authors are not certified financial advisers or tax specialists. It is recommended to seek verification from a local tax expert or the Internal Revenue Service to discuss your specific situation.

When we found out we were expecting our first child, we were ecstatic. Our excitement soon gave way to panic, however, as we realized that we needed a plan for childcare. As full-time physicians early in our careers, neither of us was prepared to drop to part-time or become a stay-at-home caregiver. Not knowing where to start, we turned to our friends and colleagues, and of course, the Internet, for advice on our options.

In our research, we discovered three things. First, with COVID-19, the cost of childcare has skyrocketed, and availability has decreased. Second, there are several options for childcare, each with its own benefits and drawbacks. Third, there is no one-size-fits-all solution. Our goal for this article is to provide an overview of the common childcare solutions and provide some practical tips to help other physicians determine what might work best for their family and situation.
 

Family

Using family members to provide childcare is often cost-effective and provides a familiar, supportive environment for children. Proximity does not guarantee a willingness or ability to provide long-term care, however, and it can cause strain on family relationships, lead to intrusions and boundary issues, and create feelings of obligation and guilt. It is important to have very honest, up-front discussions with family members about hopes and expectations if this is your childcare plan.

Daycare, facility-based

Daycare centers are commercial facilities that offer care to multiple children of varying ages, starting from as young as 6 weeks. They have trained professionals and provide structured activities and educational programs for children. Many daycares also provide snacks and lunch, which is included in their tuition. They are a popular choice for families seeking full-time childcare and the social and educational benefits that come with a structured setting.

Daycares also have some downsides. They usually operate during normal workday hours, from 7:00 a.m. to 6:00 p.m., which may not be convenient for physicians who work outside of these hours. Even with feasible hours, getting children dressed, ready, and dropped off each morning could add significant time and stress to your morning routine. Additionally, most daycares have policies that prohibit attendance if a child is sick or febrile, which is a common occurrence, particularly for daycare kids. In case of an illness outbreak, the daycare may even close for several days. Both scenarios require at least one parent to take a day off or have an alternative childcare plan available on short notice.

Availability of daycare can be limited, particularly since the COVID pandemic, creating waitlists that can be several months long. Early registration, even during pregnancy, is recommended to secure a spot. It can be helpful to find out if your employer has an agreement with a specific daycare that has “physician-friendly” hours and gives waitlist priority to trainees or even attending physicians. The cost of daycare for one child is typically affordable, around $12,000 per year on average, but can be as high as $25,000 in cities with high cost of living. A sibling discount may be offered, but the cost of daycare for multiple children could still exceed in-home childcare options.¹
 

Daycare, home-based (also known as family care centers)

Family care centers offer a home-like alternative to daycares, with smaller staff-to-child ratios and often more personalized care. They are favored by families seeking a more intimate setting. They might offer more flexible scheduling and are typically less expensive than facility-based daycares, at up to 25% lower cost.¹ They may lack the same structure and educational opportunities as facility-based daycares, however, and are not subject to the same health and safety regulations.

Nannies

Nannies are professional caregivers who provide in-home childcare services. Their responsibilities may include feeding, changing, dressing, bathing, and playing with children. In some cases, they may also be expected to do light housekeeping tasks like meal preparation, laundry, and cleaning. It is common for nannies in high-demand markets to refuse to perform these additional tasks, however. Nannies are preferred by families with hectic schedules due to their flexibility. They can work early, late, or even overnight shifts, and provide care in the comfort of your home, avoiding the hassle of drop-off and pick-up times. Nannies also can provide personalized care to meet each child’s specific needs, and they can care for children who are sick or febrile.

When hiring a nanny, it is important to have a written contract outlining their expected hours, wages, benefits, and duties to prevent misunderstandings in the future. Finding a trustworthy and reliable nanny can be a challenge, and families have several options for finding one. They can post jobs on free websites and browse nanny CVs or use a fee-based nanny agency. The cost of using an agency can range from a few hundred to several thousand dollars, so it is important to ask friends and colleagues for recommendations before paying for an agency’s services.

The cost of hiring a nanny is one of its main drawbacks. Nannies typically earn $15 to $30 per hour, and if they work in the family’s home, they are typically considered “household employees” by the IRS. Household employees are entitled to overtime pay for work beyond 40 hours per week, and the employer (you!) is responsible for payroll taxes, withholding, and providing an annual W-2 tax statement.² There are affordable online nanny payroll services that handle payroll and tax-filing to simplify the process, however. The average annual cost of a full-time nanny is around $40,000 and can be as high as $75,000 in some markets.¹ A nanny-share with other families can lower costs, but it may also result in less control over the caregiver and schedule.

It is important to consult a tax professional or the IRS for guidance on nanny wages, taxes, and payroll, as a nanny might rarely be considered an “independent contractor” if they meet certain criteria.
 

Au pair

An au pair is a live-in childcare provider who travels to a host family’s home from a foreign country on a special J-1 visa. The goal is to provide care for children and participate in cultural exchange activities. Au pairs bring many benefits, such as cost savings compared to traditional childcare options and greater flexibility and customization. They can work up to 10 hours per day and 45 hours a week, performing tasks such as light housekeeping, meal preparation, and transportation for the children. Host families must provide a safe and comfortable living environment, including a private room, meals, and some travel and education expenses.¹

The process of hiring an au pair involves working with a designated agency that matches families with applicants and sponsors the J-1 visa. The entire process can take several months, and average program fees cost around $10,000 per placement. Au pairs are hired on a 12-month J-1 visa, which can be extended for up to an additional 12 months, allowing families up to 2 years with the same au pair before needing to find a new placement.

Au pairs earn a minimum weekly stipend of $195.75, set forth by the U.S. State Department.³ Currently, au pairs are not subject to local and state wage requirements, but legal proceedings in various states have recently questioned whether au pairs should be protected under local regulations. Massachusetts has been the most progressive, explicitly protecting au pairs as domestic workers under state labor laws, raising their weekly stipend to roughly $600 to comply with state minimum wage requirements.⁴ The federal government is expected to provide clarity on this issue, but for the time being, au pairs remain an affordable alternative to a nanny in most states.
 

Conclusion

Choosing childcare is a complicated process with multiple factors to consider. Figure 1 breaks down the estimated annual cost of each of the options outlined above for a single child in low, average, and high cost-of-living areas. But your decision likely hinges on much more than just cost, and may include family dynamics, scheduling needs, and personal preferences. Gather as much advice and information as possible, but remember to trust your instincts and make the decision that works best for your family. At the end of the day, what matters most is the happiness and well-being of your child.

Dr. Hathorn and Dr. Creighton are married, and both work full-time with a 1-year-old child. Dr. Hathorn is a bariatric and advanced therapeutic endoscopist at the University of North Carolina at Chapel Hill. Dr. Creighton is an anesthesiologist at UNC Chapel Hill. Neither reported any conflicts of interest.

References

1. Care.com. This is how much childcare costs in 2022. 2022 Jun 15.

2. Internal Revenue Service. Publication 926 - Household Employer’s Tax Guide 2023.

3. U.S. Department of State. Au Pair.

4. Commonwealth of Massachusetts. Domestic workers.

Disclaimer

The financial and tax information presented in this article are believed to be true and accurate at the time of writing. However, it’s important to note that tax laws and regulations are subject to change. The authors are not certified financial advisers or tax specialists. It is recommended to seek verification from a local tax expert or the Internal Revenue Service to discuss your specific situation.

Loyalty.

This is a quality that I value in relationships. Loyalty was a significant factor contributing to my postfellowship commitment to private practice. In 2001, I graduated from physician assistant school and accepted a job with a private practice GI group in Omaha. I was fortunate to work with supportive gastroenterologists who encouraged me to pursue further training after I expressed an interest in medical school. My goal was to become a gastroenterologist but like every medical student, I would keep an open mind. My decision did not waver, and the support from my first mentors continued. As I graduated from fellowship in 2014, I gravitated toward the same private practice largely based on loyalty and my experience as a PA.

Vidyard Video

COURTESY AMERICAN GASTROENTEROLOGICAL ASSOCIATION

My experience in private practice was positive. My focus at that time and currently is clinical medicine with a focus on inflammatory bowel disease (IBD) patients. My colleagues were supportive, and I worked with a great team of nurses and APPs. I cared for many patients in both the inpatient and outpatient setting and had an opportunity to complete a high volume and variety of procedures. Overall, the various aspects of my job were rewarding. However, something was missing, and I made personal and professional adjustments. My schedule pulled me from valued family time with my kids (mostly) in the early mornings, therefore, I altered my work schedule. My clinical interest in IBD was diluted by the emphasis to see mostly general GI patients, as is the case for many in private practice. I missed the academic environment, especially working with medical students, residents, and fellows, so I occasionally had residents shadow me. Unfortunately, adjustments did not “fix” that missing component – to me, this was a job that did not feel like a career. I was not professionally fulfilled and on several occasions during the 6 years in private practice, I connected with mentors from my medical training to explore career options while trying to define what was missing.

During the latter part of years 5 and 6, it became apparent to me that loyalty pulled me toward working with a great group of supportive gastroenterologists, but it became increasingly more apparent that this job was not in line with my career goals. I had identified that I wanted to actively participate in medical education while practicing as a gastroenterologist in an academic setting. Additionally, time with my family was a critical part to the work-life integration. These tenants became part of my personal and professional mission statement, and I made the decision to further my gastroenterology career in the academic setting.

My approach to the next step in my journey was different than my initial job. My goal was to define what was important, as in what were my absolute requirements for career satisfaction and where was I willing to be flexible. Each of us has different absolute and relative requirements based on our values, and I neglected to clearly identify these components with my first job. Admittedly, I have (at times) struggled to acknowledge my values, because I might somehow appear less committed to a career. Owning these values has provided clarity in my path from private practice to academic medicine. During the 3 years I have been in my current position, I have stepped into a leadership role in the University of Nebraska Medicine GI fellowship program while providing clinical medicine at the Fred Paustian IBD Center at Nebraska Medicine. In addition, I continue to have an active endoscopy schedule and derive great satisfaction teaching the fellows how to be effective endoscopists. Personally, the difference in compensation between academic medicine and private practice was not an important factor, although this is a factor for some people (and that’s okay).

When I graduated from fellowship, my path seemed clear, and I did not anticipate the road ahead. However, with each hurdle, I was gifted with lessons that would prove to be valuable as I moved ahead. Thank you for giving me the space to share my story.
 

 

 

Lessons that have helped in my journey from private practice to academics

• Mentorship: Find mentors, not just one mentor. Over the years, I have had several mentors, but what I recognize is that, early in my career, I did not have a mentor. Although a mentor cannot make decisions for you, he/she can provide guidance from a place of experience (both career and life experience).
• Define a mission statement: My mentor pushed me to first define my values and then my mission statement. This serves as the foundation that I reference when making decisions that will impact my family and my career. For example, if I am invited to participate on a committee, I look at how this will impact my family and whether it aligns with my mission. This helps to clarify what I am willing to say yes to and what to pass along to another colleague. Remember that last part ... if you are saying no to something, suggest another colleague for the opportunity.
• Advocate for yourself: Only you know what is best for you. Sometimes the path to discovering what that is can be tortuous and require guidance. Throughout my journey, I worked with colleagues who were supportive of my journey back to medical school and supportive of my job in private practice, but only I could define what a career meant to me.
• Assume positive intent: In medicine, we frequently work in a high-stakes, stressful environment. Assume positive intent in your interactions with others, especially colleagues. This will serve you well.
• Life happens: Each of us will experience an unexpected event in our personal life or career path or both. This will be okay. The path forward may look different and require a pivot. This unexpected event might be that you find your job leaves you wanting something more or something different. Your journey will be right for you.

Dr. Hutchins is an assistant professor in the division of gastroenterology and hepatology at the University of Nebraska Medical Center, Omaha. She reported no conflicts of interest.

Loyalty.

This is a quality that I value in relationships. Loyalty was a significant factor contributing to my postfellowship commitment to private practice. In 2001, I graduated from physician assistant school and accepted a job with a private practice GI group in Omaha. I was fortunate to work with supportive gastroenterologists who encouraged me to pursue further training after I expressed an interest in medical school. My goal was to become a gastroenterologist but like every medical student, I would keep an open mind. My decision did not waver, and the support from my first mentors continued. As I graduated from fellowship in 2014, I gravitated toward the same private practice largely based on loyalty and my experience as a PA.

Vidyard Video

COURTESY AMERICAN GASTROENTEROLOGICAL ASSOCIATION

My experience in private practice was positive. My focus at that time and currently is clinical medicine with a focus on inflammatory bowel disease (IBD) patients. My colleagues were supportive, and I worked with a great team of nurses and APPs. I cared for many patients in both the inpatient and outpatient setting and had an opportunity to complete a high volume and variety of procedures. Overall, the various aspects of my job were rewarding. However, something was missing, and I made personal and professional adjustments. My schedule pulled me from valued family time with my kids (mostly) in the early mornings, therefore, I altered my work schedule. My clinical interest in IBD was diluted by the emphasis to see mostly general GI patients, as is the case for many in private practice. I missed the academic environment, especially working with medical students, residents, and fellows, so I occasionally had residents shadow me. Unfortunately, adjustments did not “fix” that missing component – to me, this was a job that did not feel like a career. I was not professionally fulfilled and on several occasions during the 6 years in private practice, I connected with mentors from my medical training to explore career options while trying to define what was missing.

During the latter part of years 5 and 6, it became apparent to me that loyalty pulled me toward working with a great group of supportive gastroenterologists, but it became increasingly more apparent that this job was not in line with my career goals. I had identified that I wanted to actively participate in medical education while practicing as a gastroenterologist in an academic setting. Additionally, time with my family was a critical part to the work-life integration. These tenants became part of my personal and professional mission statement, and I made the decision to further my gastroenterology career in the academic setting.

My approach to the next step in my journey was different than my initial job. My goal was to define what was important, as in what were my absolute requirements for career satisfaction and where was I willing to be flexible. Each of us has different absolute and relative requirements based on our values, and I neglected to clearly identify these components with my first job. Admittedly, I have (at times) struggled to acknowledge my values, because I might somehow appear less committed to a career. Owning these values has provided clarity in my path from private practice to academic medicine. During the 3 years I have been in my current position, I have stepped into a leadership role in the University of Nebraska Medicine GI fellowship program while providing clinical medicine at the Fred Paustian IBD Center at Nebraska Medicine. In addition, I continue to have an active endoscopy schedule and derive great satisfaction teaching the fellows how to be effective endoscopists. Personally, the difference in compensation between academic medicine and private practice was not an important factor, although this is a factor for some people (and that’s okay).

When I graduated from fellowship, my path seemed clear, and I did not anticipate the road ahead. However, with each hurdle, I was gifted with lessons that would prove to be valuable as I moved ahead. Thank you for giving me the space to share my story.
 

 

 

Lessons that have helped in my journey from private practice to academics

• Mentorship: Find mentors, not just one mentor. Over the years, I have had several mentors, but what I recognize is that, early in my career, I did not have a mentor. Although a mentor cannot make decisions for you, he/she can provide guidance from a place of experience (both career and life experience).
• Define a mission statement: My mentor pushed me to first define my values and then my mission statement. This serves as the foundation that I reference when making decisions that will impact my family and my career. For example, if I am invited to participate on a committee, I look at how this will impact my family and whether it aligns with my mission. This helps to clarify what I am willing to say yes to and what to pass along to another colleague. Remember that last part ... if you are saying no to something, suggest another colleague for the opportunity.
• Advocate for yourself: Only you know what is best for you. Sometimes the path to discovering what that is can be tortuous and require guidance. Throughout my journey, I worked with colleagues who were supportive of my journey back to medical school and supportive of my job in private practice, but only I could define what a career meant to me.
• Assume positive intent: In medicine, we frequently work in a high-stakes, stressful environment. Assume positive intent in your interactions with others, especially colleagues. This will serve you well.
• Life happens: Each of us will experience an unexpected event in our personal life or career path or both. This will be okay. The path forward may look different and require a pivot. This unexpected event might be that you find your job leaves you wanting something more or something different. Your journey will be right for you.

Dr. Hutchins is an assistant professor in the division of gastroenterology and hepatology at the University of Nebraska Medical Center, Omaha. She reported no conflicts of interest.

Loyalty.

This is a quality that I value in relationships. Loyalty was a significant factor contributing to my postfellowship commitment to private practice. In 2001, I graduated from physician assistant school and accepted a job with a private practice GI group in Omaha. I was fortunate to work with supportive gastroenterologists who encouraged me to pursue further training after I expressed an interest in medical school. My goal was to become a gastroenterologist but like every medical student, I would keep an open mind. My decision did not waver, and the support from my first mentors continued. As I graduated from fellowship in 2014, I gravitated toward the same private practice largely based on loyalty and my experience as a PA.

Vidyard Video

COURTESY AMERICAN GASTROENTEROLOGICAL ASSOCIATION

My experience in private practice was positive. My focus at that time and currently is clinical medicine with a focus on inflammatory bowel disease (IBD) patients. My colleagues were supportive, and I worked with a great team of nurses and APPs. I cared for many patients in both the inpatient and outpatient setting and had an opportunity to complete a high volume and variety of procedures. Overall, the various aspects of my job were rewarding. However, something was missing, and I made personal and professional adjustments. My schedule pulled me from valued family time with my kids (mostly) in the early mornings, therefore, I altered my work schedule. My clinical interest in IBD was diluted by the emphasis to see mostly general GI patients, as is the case for many in private practice. I missed the academic environment, especially working with medical students, residents, and fellows, so I occasionally had residents shadow me. Unfortunately, adjustments did not “fix” that missing component – to me, this was a job that did not feel like a career. I was not professionally fulfilled and on several occasions during the 6 years in private practice, I connected with mentors from my medical training to explore career options while trying to define what was missing.

During the latter part of years 5 and 6, it became apparent to me that loyalty pulled me toward working with a great group of supportive gastroenterologists, but it became increasingly more apparent that this job was not in line with my career goals. I had identified that I wanted to actively participate in medical education while practicing as a gastroenterologist in an academic setting. Additionally, time with my family was a critical part to the work-life integration. These tenants became part of my personal and professional mission statement, and I made the decision to further my gastroenterology career in the academic setting.

My approach to the next step in my journey was different than my initial job. My goal was to define what was important, as in what were my absolute requirements for career satisfaction and where was I willing to be flexible. Each of us has different absolute and relative requirements based on our values, and I neglected to clearly identify these components with my first job. Admittedly, I have (at times) struggled to acknowledge my values, because I might somehow appear less committed to a career. Owning these values has provided clarity in my path from private practice to academic medicine. During the 3 years I have been in my current position, I have stepped into a leadership role in the University of Nebraska Medicine GI fellowship program while providing clinical medicine at the Fred Paustian IBD Center at Nebraska Medicine. In addition, I continue to have an active endoscopy schedule and derive great satisfaction teaching the fellows how to be effective endoscopists. Personally, the difference in compensation between academic medicine and private practice was not an important factor, although this is a factor for some people (and that’s okay).

When I graduated from fellowship, my path seemed clear, and I did not anticipate the road ahead. However, with each hurdle, I was gifted with lessons that would prove to be valuable as I moved ahead. Thank you for giving me the space to share my story.
 

 

 

Lessons that have helped in my journey from private practice to academics

• Mentorship: Find mentors, not just one mentor. Over the years, I have had several mentors, but what I recognize is that, early in my career, I did not have a mentor. Although a mentor cannot make decisions for you, he/she can provide guidance from a place of experience (both career and life experience).
• Define a mission statement: My mentor pushed me to first define my values and then my mission statement. This serves as the foundation that I reference when making decisions that will impact my family and my career. For example, if I am invited to participate on a committee, I look at how this will impact my family and whether it aligns with my mission. This helps to clarify what I am willing to say yes to and what to pass along to another colleague. Remember that last part ... if you are saying no to something, suggest another colleague for the opportunity.
• Advocate for yourself: Only you know what is best for you. Sometimes the path to discovering what that is can be tortuous and require guidance. Throughout my journey, I worked with colleagues who were supportive of my journey back to medical school and supportive of my job in private practice, but only I could define what a career meant to me.
• Assume positive intent: In medicine, we frequently work in a high-stakes, stressful environment. Assume positive intent in your interactions with others, especially colleagues. This will serve you well.
• Life happens: Each of us will experience an unexpected event in our personal life or career path or both. This will be okay. The path forward may look different and require a pivot. This unexpected event might be that you find your job leaves you wanting something more or something different. Your journey will be right for you.

Dr. Hutchins is an assistant professor in the division of gastroenterology and hepatology at the University of Nebraska Medical Center, Omaha. She reported no conflicts of interest.

Evolving endpoints and treat-to-target strategies in inflammatory bowel disease (IBD) incorporate a need for more frequent assessments of the disease, including objective measures of inflammation.^1,2 Intestinal ultrasound (IUS) is a noninvasive, well-tolerated,³ repeatable, point-of-care (POC) test that is highly sensitive and specific in detection of bowel inflammation, transmural healing,^4,5 and response to therapy in both Crohn’s disease (CD) and ulcerative colitis (UC).^6-8These unique features allow IUS to be an optimal tool for the current era of disease modification and tight disease control in IBD. As IUS is taking hold in the United States, there is a great need to teach the next generation of gastroenterologists about its value, how to incorporate it into clinical practice, and how to become appropriately trained and maintain competency.

Why incorporate IUS in the United States now?

Jordan Porter-Woodruff/University of Chicago

As IBD management has evolved, so has the appreciation for the value of bedside IUS as a tool that addresses very real needs for the field. Unlike other parts of the world in which ultrasound skills are part of the training curriculum, this has not been the case in internal medicine and gastroenterology training in the United States. In addition, there have been no specific billing codes or clear renumeration processes outlined for IUS,⁹ nor have there been any local training opportunities. Because of these challenges, it was not until recently that several leaders in IBD in the United States championed the potential of this technology and incorporated it into IBD management. Subsequently, a number of gastroenterologists have been trained and are now leading the effort to disseminate this tool throughout the United States. A consequence of these efforts resulted in support from the Helmsley Charitable Trust (Helmsley) and the creation of the Intestinal Ultrasound Group of the United States and Canada to address the gaps unique to North America as well as to strengthen the quality of IUS research through collaborations across the continent.

What is IUS, and when is it performed?

IUS is a sonographic exam performed by a gastroenterology-trained professional who scans the abdominal wall (and perineum when the rectum and perineal disease is evaluated), using both a convex low-frequency probe and linear high-frequency probe to evaluate the small intestine, colon, and rectum. The bowel is composed of five layers with alternating hyperechoic and hypoechoic layers: the mucosal-lumen interface (not a true part of the bowel wall), deep mucosa, submucosa, muscularis propria, and serosa. (Figure)

Dr. Noa Krugliak Cleveland

The most sensitive parameter for assessment of IBD activity is bowel wall thickness (≤ 3 mm in the small bowel and colon and ≤ 4 mm in the rectum are considered normal in adults).^8,10 The second key parameter is the assessment of vascularization, in which presence of hyperemia suggests active disease.¹¹ There are a number of indices to quantify hyperemia, with the most widely used being the Limberg score.¹² Additional parameters include assessment of loss of the delineation of the bowel wall layers (loss of stratification signifies active inflammation), increased thickness of the submucosa,¹³ increased mesenteric fatty proliferation (with increased inflammation, mesenteric fat proliferation will appear as a hyperechoic area surrounding the bowel), lymphadenopathy, bowel strictures, and extramural complications such as fistulae and abscess. Shear wave elastography may be an effective way to differentiate severe fibrotic strictures, but this is an area that requires more investigation.¹⁴

IUS has been shown to be an excellent tool in not only assessing disease activity and disease complication (with higher sensitivity than the Harvey-Bradshaw Index, serum C-reactive protein),¹⁵ but, unique to IUS, can provide early prediction of response in moderate to severe active UC.^6,7 This has also been shown with transperineal ultrasound in patients with UC, with the ability to predict response to therapy as early as 1 week from induction therapy.¹⁶ Furthermore, it can be used to assess transmural healing, which has been shown to be associated with improved outcomes in Crohn’s patient, such as lower rates of hospitalizations, surgery, medication escalation, and need for corticosteroids.¹⁷ IUS is associated with great patient satisfaction and greater understanding of disease-related symptoms when the patient sees the inflammation of the bowel. (Table)

How can you get trained in IUS?

Training in IUS varies across the globe, from incorporation of IUS into the standard training curriculum to available training programs that can be followed and attended outside of medical training. In the United States, interested gastroenterologists can now be trained by becoming a member of the International Bowel Ultrasound Group (IBUS Group) and applying to the workshops now available. The IBUS Group has developed an IUS-specific training curriculum over the last 16 years, which is comprised of three modules: a 2-day hands-on workshop (Module 1) with final examination of theoretical competency, a preceptorship at an “expert center” with an experienced sonographer for a total of 4 weeks to complete 40 supervised IUS examinations (Module 2), and didactics and a final examination (Module 3). Also with support from Helmsley, the first Module 1 to be offered in the United States was hosted at Mount Sinai Medical Center in New York in 2022, the second was hosted at the University of Chicago in March 2023, and the third is planned to take place at Cedars-Sinai Medical Center in Los Angeles in March 2024.¹⁸ With the growing interest and demand for IUS training in the United States, U.S. experts are working to develop new training options that will be less time consuming, scalable, and still provide appropriate training and competency assessment.

University of Chicago

How do you integrate IUS into your practice?

The keys to integrating IUS are a section chief or practice manager’s support of a trainee or faculty member for both funding of equipment and protected time for training and building of the program, as well as a permissive environment and collegial relationship with radiology. An ultrasound machine and additional transducers may range in price from $50,000-$120,000. Funding may be a limiting step for many, however. A detailed business plan is imperative to the success and investment of funds in an IUS program. With current billing practices in place that include ”limited abdominal ultrasound” (76705) and “Doppler ultrasound of the abdomen” (93975),¹⁹ reimbursement should include a technical fee, professional fee, and if in a hospital-based clinic, a facility fee. IUS pro-fee combined with technical fee is reimbursed at approximately 0.80 relative value units. When possible, the facility fee is included for approximately $800 per IUS visit. For billing and compliance with HIPAA, all billed IUS images must be stored in a durable and accessible format. It is recommended that the images and cine loops be digitally stored to the same or similar platform used by radiologists at the same institution. This requires early communication with the local information technology department for the connection of an ultrasound machine to the storage platform and/or electronic health record. Reporting results should be standardized with unique or otherwise available IUS templates, which also satisfy all billing components.⁹ The flow for incorporation of IUS into practice can be at the same time patients are seen during their visit, or alternatively, in a dedicated IUS clinic in which patients are referred by other providers and scheduled back to back.

Conclusions

In summary, the confluence of treat-to-target strategies in IBD, new treatment options in IBD, and successful efforts to translate IUS training and billing practices to the United States portends a great future for the field and for our patients.

Dr. Cleveland and Dr. Rubin, of the University of Chicago’s Inflammatory Bowel Disease Center, are speakers for Samsung/Boston Imaging.

References

1. Turner D et al. Gastroenterology. Apr 2021;160(5):1570-83. doi: 10.1053/j.gastro.2020.12.031

2. Hart AL and Rubin DT. Gastroenterology. Apr 2022;162(5):1367-9. doi: 10.1053/j.gastro.2022.02.013

3. Rajagopalan A et al. JGH Open. Apr 2020;4(2):267-72. doi: 10.1002/jgh3.12268

4. Calabrese E et al. Clin Gastroenterol Hepatol. Apr 2022;20(4):e711-22. doi: 10.1016/j.cgh.2021.03.030

5. Ripolles T et al. Inflamm Bowel Dis. Oct 2016;22(10):2465-73. doi10.1097/MIB.0000000000000882

6. Maaser C et al. Gut. Sep 2020;69(9):1629-36. doi: 10.1136/gutjnl-2019-319451

7. Ilvemark J et al. J Crohns Colitis. Nov 23 2022;16(11):1725-34. doi: 10.1093/ecco-jcc/jjac083

8. Sagami S et al. Aliment Pharmacol Ther. Jun 2020;51(12):1373-83. doi: 10.1111/apt.15767

9. Dolinger MT et al. Guide to Intestinal Ultrasound Credentialing, Documentation, and Billing for Gastroenterologists in the United States. Am J Gastroenterol. 2023.

10. Maconi G et al. Ultraschall Med. Jun 2018;39(3):304-17. doi: 10.1055/s-0043-125329

11. Sasaki T et al. Scand J Gastroenterol. Mar 2014;49(3):295-301. doi: 10.3109/00365521.2013.871744

12. Limberg B. Z Gastroenterol. Jun 1999;37(6):495-508.

13. Miyoshi J et al. J Gastroenterol. Feb 2022;57(2):82-9. doi: 10.1007/s00535-021-01847-3

14. Chen YJ et al. Inflamm Bowel Dis. Sep 15 2018;24(10):2183-90. doi: 10.1093/ibd/izy115

15. Kucharzik T et al. Apr 2017;15(4):535-42e2. doi: 10.1016/j.cgh.2016.10.040

16. Sagami S et al. Aliment Pharmacol Ther. May 2022;55(10):1320-9. doi: 10.1111/apt.16817

17. Vaughan R et al. Aliment Pharmacol Ther. Jul 2022;56(1):84-94. doi: 10.1111/apt.16892

18. International Bowel Ultrasound Group. https://ibus-group.org/

19. American Medical Association. CPT (Current Procedural Terminology). https://www.ama-assn.org/amaone/cpt-current-procedural-terminology




 

Evolving endpoints and treat-to-target strategies in inflammatory bowel disease (IBD) incorporate a need for more frequent assessments of the disease, including objective measures of inflammation.^1,2 Intestinal ultrasound (IUS) is a noninvasive, well-tolerated,³ repeatable, point-of-care (POC) test that is highly sensitive and specific in detection of bowel inflammation, transmural healing,^4,5 and response to therapy in both Crohn’s disease (CD) and ulcerative colitis (UC).^6-8These unique features allow IUS to be an optimal tool for the current era of disease modification and tight disease control in IBD. As IUS is taking hold in the United States, there is a great need to teach the next generation of gastroenterologists about its value, how to incorporate it into clinical practice, and how to become appropriately trained and maintain competency.

Why incorporate IUS in the United States now?

Jordan Porter-Woodruff/University of Chicago

As IBD management has evolved, so has the appreciation for the value of bedside IUS as a tool that addresses very real needs for the field. Unlike other parts of the world in which ultrasound skills are part of the training curriculum, this has not been the case in internal medicine and gastroenterology training in the United States. In addition, there have been no specific billing codes or clear renumeration processes outlined for IUS,⁹ nor have there been any local training opportunities. Because of these challenges, it was not until recently that several leaders in IBD in the United States championed the potential of this technology and incorporated it into IBD management. Subsequently, a number of gastroenterologists have been trained and are now leading the effort to disseminate this tool throughout the United States. A consequence of these efforts resulted in support from the Helmsley Charitable Trust (Helmsley) and the creation of the Intestinal Ultrasound Group of the United States and Canada to address the gaps unique to North America as well as to strengthen the quality of IUS research through collaborations across the continent.

What is IUS, and when is it performed?

IUS is a sonographic exam performed by a gastroenterology-trained professional who scans the abdominal wall (and perineum when the rectum and perineal disease is evaluated), using both a convex low-frequency probe and linear high-frequency probe to evaluate the small intestine, colon, and rectum. The bowel is composed of five layers with alternating hyperechoic and hypoechoic layers: the mucosal-lumen interface (not a true part of the bowel wall), deep mucosa, submucosa, muscularis propria, and serosa. (Figure)

Dr. Noa Krugliak Cleveland

The most sensitive parameter for assessment of IBD activity is bowel wall thickness (≤ 3 mm in the small bowel and colon and ≤ 4 mm in the rectum are considered normal in adults).^8,10 The second key parameter is the assessment of vascularization, in which presence of hyperemia suggests active disease.¹¹ There are a number of indices to quantify hyperemia, with the most widely used being the Limberg score.¹² Additional parameters include assessment of loss of the delineation of the bowel wall layers (loss of stratification signifies active inflammation), increased thickness of the submucosa,¹³ increased mesenteric fatty proliferation (with increased inflammation, mesenteric fat proliferation will appear as a hyperechoic area surrounding the bowel), lymphadenopathy, bowel strictures, and extramural complications such as fistulae and abscess. Shear wave elastography may be an effective way to differentiate severe fibrotic strictures, but this is an area that requires more investigation.¹⁴

IUS has been shown to be an excellent tool in not only assessing disease activity and disease complication (with higher sensitivity than the Harvey-Bradshaw Index, serum C-reactive protein),¹⁵ but, unique to IUS, can provide early prediction of response in moderate to severe active UC.^6,7 This has also been shown with transperineal ultrasound in patients with UC, with the ability to predict response to therapy as early as 1 week from induction therapy.¹⁶ Furthermore, it can be used to assess transmural healing, which has been shown to be associated with improved outcomes in Crohn’s patient, such as lower rates of hospitalizations, surgery, medication escalation, and need for corticosteroids.¹⁷ IUS is associated with great patient satisfaction and greater understanding of disease-related symptoms when the patient sees the inflammation of the bowel. (Table)

How can you get trained in IUS?

Training in IUS varies across the globe, from incorporation of IUS into the standard training curriculum to available training programs that can be followed and attended outside of medical training. In the United States, interested gastroenterologists can now be trained by becoming a member of the International Bowel Ultrasound Group (IBUS Group) and applying to the workshops now available. The IBUS Group has developed an IUS-specific training curriculum over the last 16 years, which is comprised of three modules: a 2-day hands-on workshop (Module 1) with final examination of theoretical competency, a preceptorship at an “expert center” with an experienced sonographer for a total of 4 weeks to complete 40 supervised IUS examinations (Module 2), and didactics and a final examination (Module 3). Also with support from Helmsley, the first Module 1 to be offered in the United States was hosted at Mount Sinai Medical Center in New York in 2022, the second was hosted at the University of Chicago in March 2023, and the third is planned to take place at Cedars-Sinai Medical Center in Los Angeles in March 2024.¹⁸ With the growing interest and demand for IUS training in the United States, U.S. experts are working to develop new training options that will be less time consuming, scalable, and still provide appropriate training and competency assessment.

University of Chicago

How do you integrate IUS into your practice?

The keys to integrating IUS are a section chief or practice manager’s support of a trainee or faculty member for both funding of equipment and protected time for training and building of the program, as well as a permissive environment and collegial relationship with radiology. An ultrasound machine and additional transducers may range in price from $50,000-$120,000. Funding may be a limiting step for many, however. A detailed business plan is imperative to the success and investment of funds in an IUS program. With current billing practices in place that include ”limited abdominal ultrasound” (76705) and “Doppler ultrasound of the abdomen” (93975),¹⁹ reimbursement should include a technical fee, professional fee, and if in a hospital-based clinic, a facility fee. IUS pro-fee combined with technical fee is reimbursed at approximately 0.80 relative value units. When possible, the facility fee is included for approximately $800 per IUS visit. For billing and compliance with HIPAA, all billed IUS images must be stored in a durable and accessible format. It is recommended that the images and cine loops be digitally stored to the same or similar platform used by radiologists at the same institution. This requires early communication with the local information technology department for the connection of an ultrasound machine to the storage platform and/or electronic health record. Reporting results should be standardized with unique or otherwise available IUS templates, which also satisfy all billing components.⁹ The flow for incorporation of IUS into practice can be at the same time patients are seen during their visit, or alternatively, in a dedicated IUS clinic in which patients are referred by other providers and scheduled back to back.

Conclusions

In summary, the confluence of treat-to-target strategies in IBD, new treatment options in IBD, and successful efforts to translate IUS training and billing practices to the United States portends a great future for the field and for our patients.

Dr. Cleveland and Dr. Rubin, of the University of Chicago’s Inflammatory Bowel Disease Center, are speakers for Samsung/Boston Imaging.

References

1. Turner D et al. Gastroenterology. Apr 2021;160(5):1570-83. doi: 10.1053/j.gastro.2020.12.031

2. Hart AL and Rubin DT. Gastroenterology. Apr 2022;162(5):1367-9. doi: 10.1053/j.gastro.2022.02.013

3. Rajagopalan A et al. JGH Open. Apr 2020;4(2):267-72. doi: 10.1002/jgh3.12268

4. Calabrese E et al. Clin Gastroenterol Hepatol. Apr 2022;20(4):e711-22. doi: 10.1016/j.cgh.2021.03.030

5. Ripolles T et al. Inflamm Bowel Dis. Oct 2016;22(10):2465-73. doi10.1097/MIB.0000000000000882

6. Maaser C et al. Gut. Sep 2020;69(9):1629-36. doi: 10.1136/gutjnl-2019-319451

7. Ilvemark J et al. J Crohns Colitis. Nov 23 2022;16(11):1725-34. doi: 10.1093/ecco-jcc/jjac083

8. Sagami S et al. Aliment Pharmacol Ther. Jun 2020;51(12):1373-83. doi: 10.1111/apt.15767

9. Dolinger MT et al. Guide to Intestinal Ultrasound Credentialing, Documentation, and Billing for Gastroenterologists in the United States. Am J Gastroenterol. 2023.

10. Maconi G et al. Ultraschall Med. Jun 2018;39(3):304-17. doi: 10.1055/s-0043-125329

11. Sasaki T et al. Scand J Gastroenterol. Mar 2014;49(3):295-301. doi: 10.3109/00365521.2013.871744

12. Limberg B. Z Gastroenterol. Jun 1999;37(6):495-508.

13. Miyoshi J et al. J Gastroenterol. Feb 2022;57(2):82-9. doi: 10.1007/s00535-021-01847-3

14. Chen YJ et al. Inflamm Bowel Dis. Sep 15 2018;24(10):2183-90. doi: 10.1093/ibd/izy115

15. Kucharzik T et al. Apr 2017;15(4):535-42e2. doi: 10.1016/j.cgh.2016.10.040

16. Sagami S et al. Aliment Pharmacol Ther. May 2022;55(10):1320-9. doi: 10.1111/apt.16817

17. Vaughan R et al. Aliment Pharmacol Ther. Jul 2022;56(1):84-94. doi: 10.1111/apt.16892

18. International Bowel Ultrasound Group. https://ibus-group.org/

19. American Medical Association. CPT (Current Procedural Terminology). https://www.ama-assn.org/amaone/cpt-current-procedural-terminology




 

Evolving endpoints and treat-to-target strategies in inflammatory bowel disease (IBD) incorporate a need for more frequent assessments of the disease, including objective measures of inflammation.^1,2 Intestinal ultrasound (IUS) is a noninvasive, well-tolerated,³ repeatable, point-of-care (POC) test that is highly sensitive and specific in detection of bowel inflammation, transmural healing,^4,5 and response to therapy in both Crohn’s disease (CD) and ulcerative colitis (UC).^6-8These unique features allow IUS to be an optimal tool for the current era of disease modification and tight disease control in IBD. As IUS is taking hold in the United States, there is a great need to teach the next generation of gastroenterologists about its value, how to incorporate it into clinical practice, and how to become appropriately trained and maintain competency.

Why incorporate IUS in the United States now?

Jordan Porter-Woodruff/University of Chicago

As IBD management has evolved, so has the appreciation for the value of bedside IUS as a tool that addresses very real needs for the field. Unlike other parts of the world in which ultrasound skills are part of the training curriculum, this has not been the case in internal medicine and gastroenterology training in the United States. In addition, there have been no specific billing codes or clear renumeration processes outlined for IUS,⁹ nor have there been any local training opportunities. Because of these challenges, it was not until recently that several leaders in IBD in the United States championed the potential of this technology and incorporated it into IBD management. Subsequently, a number of gastroenterologists have been trained and are now leading the effort to disseminate this tool throughout the United States. A consequence of these efforts resulted in support from the Helmsley Charitable Trust (Helmsley) and the creation of the Intestinal Ultrasound Group of the United States and Canada to address the gaps unique to North America as well as to strengthen the quality of IUS research through collaborations across the continent.

What is IUS, and when is it performed?

IUS is a sonographic exam performed by a gastroenterology-trained professional who scans the abdominal wall (and perineum when the rectum and perineal disease is evaluated), using both a convex low-frequency probe and linear high-frequency probe to evaluate the small intestine, colon, and rectum. The bowel is composed of five layers with alternating hyperechoic and hypoechoic layers: the mucosal-lumen interface (not a true part of the bowel wall), deep mucosa, submucosa, muscularis propria, and serosa. (Figure)

Dr. Noa Krugliak Cleveland

The most sensitive parameter for assessment of IBD activity is bowel wall thickness (≤ 3 mm in the small bowel and colon and ≤ 4 mm in the rectum are considered normal in adults).^8,10 The second key parameter is the assessment of vascularization, in which presence of hyperemia suggests active disease.¹¹ There are a number of indices to quantify hyperemia, with the most widely used being the Limberg score.¹² Additional parameters include assessment of loss of the delineation of the bowel wall layers (loss of stratification signifies active inflammation), increased thickness of the submucosa,¹³ increased mesenteric fatty proliferation (with increased inflammation, mesenteric fat proliferation will appear as a hyperechoic area surrounding the bowel), lymphadenopathy, bowel strictures, and extramural complications such as fistulae and abscess. Shear wave elastography may be an effective way to differentiate severe fibrotic strictures, but this is an area that requires more investigation.¹⁴

IUS has been shown to be an excellent tool in not only assessing disease activity and disease complication (with higher sensitivity than the Harvey-Bradshaw Index, serum C-reactive protein),¹⁵ but, unique to IUS, can provide early prediction of response in moderate to severe active UC.^6,7 This has also been shown with transperineal ultrasound in patients with UC, with the ability to predict response to therapy as early as 1 week from induction therapy.¹⁶ Furthermore, it can be used to assess transmural healing, which has been shown to be associated with improved outcomes in Crohn’s patient, such as lower rates of hospitalizations, surgery, medication escalation, and need for corticosteroids.¹⁷ IUS is associated with great patient satisfaction and greater understanding of disease-related symptoms when the patient sees the inflammation of the bowel. (Table)

How can you get trained in IUS?

Training in IUS varies across the globe, from incorporation of IUS into the standard training curriculum to available training programs that can be followed and attended outside of medical training. In the United States, interested gastroenterologists can now be trained by becoming a member of the International Bowel Ultrasound Group (IBUS Group) and applying to the workshops now available. The IBUS Group has developed an IUS-specific training curriculum over the last 16 years, which is comprised of three modules: a 2-day hands-on workshop (Module 1) with final examination of theoretical competency, a preceptorship at an “expert center” with an experienced sonographer for a total of 4 weeks to complete 40 supervised IUS examinations (Module 2), and didactics and a final examination (Module 3). Also with support from Helmsley, the first Module 1 to be offered in the United States was hosted at Mount Sinai Medical Center in New York in 2022, the second was hosted at the University of Chicago in March 2023, and the third is planned to take place at Cedars-Sinai Medical Center in Los Angeles in March 2024.¹⁸ With the growing interest and demand for IUS training in the United States, U.S. experts are working to develop new training options that will be less time consuming, scalable, and still provide appropriate training and competency assessment.

University of Chicago

How do you integrate IUS into your practice?

The keys to integrating IUS are a section chief or practice manager’s support of a trainee or faculty member for both funding of equipment and protected time for training and building of the program, as well as a permissive environment and collegial relationship with radiology. An ultrasound machine and additional transducers may range in price from $50,000-$120,000. Funding may be a limiting step for many, however. A detailed business plan is imperative to the success and investment of funds in an IUS program. With current billing practices in place that include ”limited abdominal ultrasound” (76705) and “Doppler ultrasound of the abdomen” (93975),¹⁹ reimbursement should include a technical fee, professional fee, and if in a hospital-based clinic, a facility fee. IUS pro-fee combined with technical fee is reimbursed at approximately 0.80 relative value units. When possible, the facility fee is included for approximately $800 per IUS visit. For billing and compliance with HIPAA, all billed IUS images must be stored in a durable and accessible format. It is recommended that the images and cine loops be digitally stored to the same or similar platform used by radiologists at the same institution. This requires early communication with the local information technology department for the connection of an ultrasound machine to the storage platform and/or electronic health record. Reporting results should be standardized with unique or otherwise available IUS templates, which also satisfy all billing components.⁹ The flow for incorporation of IUS into practice can be at the same time patients are seen during their visit, or alternatively, in a dedicated IUS clinic in which patients are referred by other providers and scheduled back to back.

Conclusions

In summary, the confluence of treat-to-target strategies in IBD, new treatment options in IBD, and successful efforts to translate IUS training and billing practices to the United States portends a great future for the field and for our patients.

Dr. Cleveland and Dr. Rubin, of the University of Chicago’s Inflammatory Bowel Disease Center, are speakers for Samsung/Boston Imaging.

References

1. Turner D et al. Gastroenterology. Apr 2021;160(5):1570-83. doi: 10.1053/j.gastro.2020.12.031

2. Hart AL and Rubin DT. Gastroenterology. Apr 2022;162(5):1367-9. doi: 10.1053/j.gastro.2022.02.013

3. Rajagopalan A et al. JGH Open. Apr 2020;4(2):267-72. doi: 10.1002/jgh3.12268

4. Calabrese E et al. Clin Gastroenterol Hepatol. Apr 2022;20(4):e711-22. doi: 10.1016/j.cgh.2021.03.030

5. Ripolles T et al. Inflamm Bowel Dis. Oct 2016;22(10):2465-73. doi10.1097/MIB.0000000000000882

6. Maaser C et al. Gut. Sep 2020;69(9):1629-36. doi: 10.1136/gutjnl-2019-319451

7. Ilvemark J et al. J Crohns Colitis. Nov 23 2022;16(11):1725-34. doi: 10.1093/ecco-jcc/jjac083

8. Sagami S et al. Aliment Pharmacol Ther. Jun 2020;51(12):1373-83. doi: 10.1111/apt.15767

9. Dolinger MT et al. Guide to Intestinal Ultrasound Credentialing, Documentation, and Billing for Gastroenterologists in the United States. Am J Gastroenterol. 2023.

10. Maconi G et al. Ultraschall Med. Jun 2018;39(3):304-17. doi: 10.1055/s-0043-125329

11. Sasaki T et al. Scand J Gastroenterol. Mar 2014;49(3):295-301. doi: 10.3109/00365521.2013.871744

12. Limberg B. Z Gastroenterol. Jun 1999;37(6):495-508.

13. Miyoshi J et al. J Gastroenterol. Feb 2022;57(2):82-9. doi: 10.1007/s00535-021-01847-3

14. Chen YJ et al. Inflamm Bowel Dis. Sep 15 2018;24(10):2183-90. doi: 10.1093/ibd/izy115

15. Kucharzik T et al. Apr 2017;15(4):535-42e2. doi: 10.1016/j.cgh.2016.10.040

16. Sagami S et al. Aliment Pharmacol Ther. May 2022;55(10):1320-9. doi: 10.1111/apt.16817

17. Vaughan R et al. Aliment Pharmacol Ther. Jul 2022;56(1):84-94. doi: 10.1111/apt.16892

18. International Bowel Ultrasound Group. https://ibus-group.org/

19. American Medical Association. CPT (Current Procedural Terminology). https://www.ama-assn.org/amaone/cpt-current-procedural-terminology




 

Recruiting medical trainees is a major yearly step for all teaching hospitals in health care. The concept of interviewing residents and fellows virtually is not completely new and has been used in the past.¹ With the coronavirus disease-19 (COVID-19) epidemic, the Association of American Medical Colleges (AAMC) recommended in May 2020 that all interviews be conducted virtually to ensure safety and prevent spread of the disease.^2,3 Over the past few years, and with the gradual loosening of some restrictions, some programs have adopted a hybrid interview model for their recruitment plan, while others continue to use the virtual model exclusively.

In this paper, we share our personal experience with recruiting gastroenterology and hepatology fellows virtually, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.

After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.

When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.

It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.^4-9

Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.¹¹ Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.⁶ These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.

As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,¹² and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.

In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
 

Survey

A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?

1. I was provided with all the information I needed to know, and I had a great understanding of the program

2. I was provided with some information, and I had a fair understanding of the program

3. I was not provided with enough information, and I don’t think I understand the program well



B. How likely were you to accept this interview if this had been an in-person interview?

1. I would have still accepted the invitation regardless

2. I would have thought about possibly not accepting the invitation

3. I wouldn’t have accepted the invitation



C. Do you think an in-person interview would have changed your program ranking?

1. Yes

2. Maybe, I am not sure

3. No



D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?

1. Virtual

2. In-person



E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?

1. Quite satisfied

2. Somewhat satisfied

3. Not at all satisfied



F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?

1. Yes

2. No



H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
 

I. Additional comments:
 

Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.

References

1. Shah SK et al. Randomized evaluation of a web based interview process for urology resident selection. J Urol. Apr 2012;187(4):1380-4.

2. AAMC Interview Guidance for the 2022-2023 Residency Cycle. May 16, 2022.

3. Bernstein SA et al. Graduate medical education virtual interviews and recruitment in the era of COVID-19. J Grad Med Educ. Oct 2020;12(5):557-60.

4. Gupta S et al. Is the changing landscape of fellowship recruitment during COVID-19 here to stay? J Pediatr Surg. Oct 2022;57(10):445-50.

5. Vining CC et al. Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future. Ann Surg Oncol. 2020 Dec;27(Suppl 3):911-15.

6. Simmons RP et al. Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors. Am J Med. Feb 2022;135(2):258-63.e251.

7. Daram SR et al. Interview from anywhere: Feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process. Am J Gastroenterol. Feb 2014;109(2):155-9.

8. Ponterio JM et al. The virtual interview format for fellowship recruitment in obstetrics and gynecology: A nationwide survey of program directors. Med Educ Online. Dec 2022;27(1):2054304.

9. DiGiusto M et al. Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors. Paediatr Anaesth. Mar 2022;32(3):471-8.

10. Hamade N et al. Virtual Gastroenterology Fellowship Recruitment During COVID-19 and Its Implications for the Future. Dig Dis Sci. Jun 2022;67(6):2019-28.

11. AAMC: ERAS Statistics. Historical Specialty Specific Data.

12. Advani R et al. An Overview of the GI Fellowship Interview: Part II-Tips for Selection Committees and Interviewers. Dig Dis Sci. May 2022;67(5):1712-17.

Recruiting medical trainees is a major yearly step for all teaching hospitals in health care. The concept of interviewing residents and fellows virtually is not completely new and has been used in the past.¹ With the coronavirus disease-19 (COVID-19) epidemic, the Association of American Medical Colleges (AAMC) recommended in May 2020 that all interviews be conducted virtually to ensure safety and prevent spread of the disease.^2,3 Over the past few years, and with the gradual loosening of some restrictions, some programs have adopted a hybrid interview model for their recruitment plan, while others continue to use the virtual model exclusively.

In this paper, we share our personal experience with recruiting gastroenterology and hepatology fellows virtually, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.

After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.

When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.

It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.^4-9

Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.¹¹ Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.⁶ These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.

As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,¹² and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.

In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
 

Survey

A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?

1. I was provided with all the information I needed to know, and I had a great understanding of the program

2. I was provided with some information, and I had a fair understanding of the program

3. I was not provided with enough information, and I don’t think I understand the program well



B. How likely were you to accept this interview if this had been an in-person interview?

1. I would have still accepted the invitation regardless

2. I would have thought about possibly not accepting the invitation

3. I wouldn’t have accepted the invitation



C. Do you think an in-person interview would have changed your program ranking?

1. Yes

2. Maybe, I am not sure

3. No



D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?

1. Virtual

2. In-person



E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?

1. Quite satisfied

2. Somewhat satisfied

3. Not at all satisfied



F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?

1. Yes

2. No



H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
 

I. Additional comments:
 

Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.

References

1. Shah SK et al. Randomized evaluation of a web based interview process for urology resident selection. J Urol. Apr 2012;187(4):1380-4.

2. AAMC Interview Guidance for the 2022-2023 Residency Cycle. May 16, 2022.

3. Bernstein SA et al. Graduate medical education virtual interviews and recruitment in the era of COVID-19. J Grad Med Educ. Oct 2020;12(5):557-60.

4. Gupta S et al. Is the changing landscape of fellowship recruitment during COVID-19 here to stay? J Pediatr Surg. Oct 2022;57(10):445-50.

5. Vining CC et al. Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future. Ann Surg Oncol. 2020 Dec;27(Suppl 3):911-15.

6. Simmons RP et al. Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors. Am J Med. Feb 2022;135(2):258-63.e251.

7. Daram SR et al. Interview from anywhere: Feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process. Am J Gastroenterol. Feb 2014;109(2):155-9.

8. Ponterio JM et al. The virtual interview format for fellowship recruitment in obstetrics and gynecology: A nationwide survey of program directors. Med Educ Online. Dec 2022;27(1):2054304.

9. DiGiusto M et al. Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors. Paediatr Anaesth. Mar 2022;32(3):471-8.

10. Hamade N et al. Virtual Gastroenterology Fellowship Recruitment During COVID-19 and Its Implications for the Future. Dig Dis Sci. Jun 2022;67(6):2019-28.

11. AAMC: ERAS Statistics. Historical Specialty Specific Data.

12. Advani R et al. An Overview of the GI Fellowship Interview: Part II-Tips for Selection Committees and Interviewers. Dig Dis Sci. May 2022;67(5):1712-17.

Recruiting medical trainees is a major yearly step for all teaching hospitals in health care. The concept of interviewing residents and fellows virtually is not completely new and has been used in the past.¹ With the coronavirus disease-19 (COVID-19) epidemic, the Association of American Medical Colleges (AAMC) recommended in May 2020 that all interviews be conducted virtually to ensure safety and prevent spread of the disease.^2,3 Over the past few years, and with the gradual loosening of some restrictions, some programs have adopted a hybrid interview model for their recruitment plan, while others continue to use the virtual model exclusively.

In this paper, we share our personal experience with recruiting gastroenterology and hepatology fellows virtually, from the standpoint of the program director (Dr. Clark) and the associate program director (Dr. Dakhoul) of the fellowship program at the University of Florida in Gainesville. We have conducted our fellowship interviews for the academic year 2022-2023 completely virtually over multiple half-day sessions and fully matched all four positions. At the time of the interviews, we extended a general invitation to all candidates for an in-person visit for the purpose of touring the facilities and our community. Out of the 37 applicants interviewed, 2 made an in-person visit later.

After we concluded the interview season, we conducted a brief, anonymous survey to assess the overall experience of the interviewees with their virtual interviews. (See end of this article.) The survey contained a combination of single-choice questions and open-ended questions. The response rate was 35%. Most responders (92.3%) thought that they had a great understanding of the program from the information provided to them, and 84.6% were quite satisfied with their virtual interview experience. Regarding the likelihood of accepting the interview if it were offered in person, only one person answered that he/she would not have accepted the invitation. A total of 31% of participants might have changed the ranking of the program if they’d had an in-person interview instead.

When asked to choose between an invitation for an in-person vs. a virtual interview, the majority (77%) chose the virtual option. The stated pros of being interviewed virtually included convenience (not having to find coverage, etc.), time and cost savings, and a less stressful experience. Cons were focused mostly on not being able to see the hospital or the geographical area in person, as well as limited exposure to the facility and work environment for subjective assessment of “fitting” into the program. Additional comments included mostly positive feedback about the whole experience specific to the program. Finally, 77% of respondents recommended that the program should continue to conduct its interviews virtually.

It seems that the general feedback from our survey was positive. Certainly, limitations exist, including but not limited to the response rate, the geographic locations of the invited candidates, the design of the interview day, and familiarity with the fellowship program and the surrounding area. Several studies have been published on the topic with variable results across centers and among specialties, but most of them reported an encouraging overall experience.^4-9

Furthermore, the number of candidates who applied to our program has been steadily on the rise since the virtual platform was introduced. This has been the case nationwide and in other specialties as well.¹¹ Applicants invited for an interview rarely decline or cancel the invitation due to the convenience of the virtual setting.⁶ These factors can affect the choice of candidates and subsequently the results of the match, especially for smaller programs. These observations create a new dilemma of whether fellowship programs need to consider increasing the number of their interviewees to ascertain a full match. Although the number of gastroenterology fellowship positions is steadily increasing with new program openings every year, it might not match the speed of the up-trending number of applicants. This certainly creates concern for fairness and equity in the selection process in this very competitive subspecialty.

As most gastroenterology programs continue to recruit their fellows virtually, it is important to keep in mind a few key elements to enhance the virtual experience. These include: a) familiarity of the interviewers and interviewees with video conference software to avoid technical problems, b) inclusion of up-to-date information about the program on the institutional website as well as videos or live-stream tours to show the physical aspect of the training sites (mainly the endoscopy areas) as alternatives to in-person tours,¹² and c) timing of the interview, taking into consideration the different time zones of the invited applicants. Despite optimizing the virtual experience, some interviewees might still choose to visit in person. While this decision is solely voluntary and remains optional (at least in our program), it does allow program directors to indirectly evaluate candidates with a strong interest in the program.

In conclusion, there is no clear-cut answer to whether conducting interviews virtually is the best way to continue to recruit gastroenterology and hepatology fellows beyond the pandemic. While our perspective might be somewhat biased by the positive experience we had in the past few years recruiting our fellows virtually, this should be an individualized decision for every program. It is highly dependent on the location and size of each fellowship program, faculty engagement in the interview process, and the historical matching rates of the program. On a positive note, the individualized approach by each fellowship program should highlight the best features of the program and have a positive impact on recruitment at the local level. We have to bear in mind that a nonstandardized approach to fellow recruitment may have disadvantages to both programs and applicants with fewer resources to successfully compete and may introduce another element of uncertainty to an already stressful process for applicants and programs alike. As we continue to understand the implications of using the virtual platform and to reflect on the previous match results through the performance and satisfaction of the fellows recruited virtually, this option does not seem to have completely replaced in-person meetings. Further follow-up to evaluate the impact of virtual interviews should be done by surveying program directors nationally on the impact of match results before and after implementation of virtual interviews.
 

Survey

A. Do you think you had a good understanding of the UF GI Fellowship program from the information provided to you during your virtual interview?

1. I was provided with all the information I needed to know, and I had a great understanding of the program

2. I was provided with some information, and I had a fair understanding of the program

3. I was not provided with enough information, and I don’t think I understand the program well



B. How likely were you to accept this interview if this had been an in-person interview?

1. I would have still accepted the invitation regardless

2. I would have thought about possibly not accepting the invitation

3. I wouldn’t have accepted the invitation



C. Do you think an in-person interview would have changed your program ranking?

1. Yes

2. Maybe, I am not sure

3. No



D. If you had a choice between conducting this interview virtually vs. in-person, which one would you have chosen?

1. Virtual

2. In-person



E. Overall, how satisfied were you with your virtual GI Fellowship interview experience at UF?

1. Quite satisfied

2. Somewhat satisfied

3. Not at all satisfied



F. If you chose “somewhat satisfied” or “not at all satisfied” in the previous question, please tell us why, and what are the things that we could have done better:G. Do you think the UF GI Fellowship program should continue to conduct its interviews virtually (regardless of COVID)?

1. Yes

2. No



H. Please list some of the pros and cons of being interviewed virtually, in your opinion:
 

I. Additional comments:
 

Dr. Dakhoul, Ms. Rhoden, and Dr. Clark are with the division of gastroenterology and hepatology, University of Florida, Gainesville. They have no disclosures or conflicts.

References

1. Shah SK et al. Randomized evaluation of a web based interview process for urology resident selection. J Urol. Apr 2012;187(4):1380-4.

2. AAMC Interview Guidance for the 2022-2023 Residency Cycle. May 16, 2022.

3. Bernstein SA et al. Graduate medical education virtual interviews and recruitment in the era of COVID-19. J Grad Med Educ. Oct 2020;12(5):557-60.

4. Gupta S et al. Is the changing landscape of fellowship recruitment during COVID-19 here to stay? J Pediatr Surg. Oct 2022;57(10):445-50.

5. Vining CC et al. Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future. Ann Surg Oncol. 2020 Dec;27(Suppl 3):911-15.

6. Simmons RP et al. Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors. Am J Med. Feb 2022;135(2):258-63.e251.

7. Daram SR et al. Interview from anywhere: Feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process. Am J Gastroenterol. Feb 2014;109(2):155-9.

8. Ponterio JM et al. The virtual interview format for fellowship recruitment in obstetrics and gynecology: A nationwide survey of program directors. Med Educ Online. Dec 2022;27(1):2054304.

9. DiGiusto M et al. Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors. Paediatr Anaesth. Mar 2022;32(3):471-8.

10. Hamade N et al. Virtual Gastroenterology Fellowship Recruitment During COVID-19 and Its Implications for the Future. Dig Dis Sci. Jun 2022;67(6):2019-28.

11. AAMC: ERAS Statistics. Historical Specialty Specific Data.

12. Advani R et al. An Overview of the GI Fellowship Interview: Part II-Tips for Selection Committees and Interviewers. Dig Dis Sci. May 2022;67(5):1712-17.

Dear friends,

Since the last issue of The New Gastroenterologist, the GI Fellowship Match has occurred and CONGRATULATIONS to the Class of 2026! You’ve all been on an arduous journey to get here, and it’s really time to slow down and soak up as much as you can. For those who did not match, do not give up, because you are still the future of GI!

This issue of TNG is particularly special to me, because it marks my first official selection of articles as I embark on my own TNG journey, and the theme is the future of GI. In the “In Focus” article this quarter, Dr. Eugenia N. Uche-Anya and Dr. Tyler M. Berzin review the vast and emerging advances of artificial intelligence (AI) in colonoscopy, its role in augmenting patient care, obstacles in incorporating AI into current practice, and the future of AI in gastroenterology and hepatology. One important aspect of developing our future in these technologies includes getting involved with industry. Dr. Raman Muthusamy gives practical tips on developing and navigating relationships with industry, with highlights on understanding intellectual property and conflicts of interest.

Continuing our trek into the future of GI, telemedicine came into the fold with the COVID-19 pandemic, and it is clearly here to stay. Dr. Russ R. Arjal repositions telemedicine as a way to increase access to care and optimize practice revenue, with the aim of improving patient outcomes in the future.

Last, to ground this issue clinically, Dr. Jason Kwon and Dr. Paul T. Kroner review the gastrointestinal, hepatic, and pancreaticobiliary adverse manifestations and management of immune checkpoint inhibitors, especially now that immunotherapies have revolutionized the treatment of cancer. As gastroenterologists, we are and will be seeing more and more of these adverse events.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]). You may also contact Jillian Schweitzer ([email protected]), managing editor of TNG.

Until next time, I leave you with a historical fun fact: Philipp Bozzini is credited with having developed the first endoscope in 1805, called the Lichtleiter (German for “light conductor”), using a candle as its light source. Adolf Kussmaul, however, developed the first rigid gastroscope in 1868, recruiting a sword-swallower in his first demonstration.


Yours truly,

Judy A. Trieu, MD, MPH
Editor-in-Chief
Advanced Endoscopy Fellow
Division of Gastroenterology & Hepatology
University of North Carolina at Chapel Hill

Dear friends,

Since the last issue of The New Gastroenterologist, the GI Fellowship Match has occurred and CONGRATULATIONS to the Class of 2026! You’ve all been on an arduous journey to get here, and it’s really time to slow down and soak up as much as you can. For those who did not match, do not give up, because you are still the future of GI!

This issue of TNG is particularly special to me, because it marks my first official selection of articles as I embark on my own TNG journey, and the theme is the future of GI. In the “In Focus” article this quarter, Dr. Eugenia N. Uche-Anya and Dr. Tyler M. Berzin review the vast and emerging advances of artificial intelligence (AI) in colonoscopy, its role in augmenting patient care, obstacles in incorporating AI into current practice, and the future of AI in gastroenterology and hepatology. One important aspect of developing our future in these technologies includes getting involved with industry. Dr. Raman Muthusamy gives practical tips on developing and navigating relationships with industry, with highlights on understanding intellectual property and conflicts of interest.

Continuing our trek into the future of GI, telemedicine came into the fold with the COVID-19 pandemic, and it is clearly here to stay. Dr. Russ R. Arjal repositions telemedicine as a way to increase access to care and optimize practice revenue, with the aim of improving patient outcomes in the future.

Last, to ground this issue clinically, Dr. Jason Kwon and Dr. Paul T. Kroner review the gastrointestinal, hepatic, and pancreaticobiliary adverse manifestations and management of immune checkpoint inhibitors, especially now that immunotherapies have revolutionized the treatment of cancer. As gastroenterologists, we are and will be seeing more and more of these adverse events.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]). You may also contact Jillian Schweitzer ([email protected]), managing editor of TNG.

Until next time, I leave you with a historical fun fact: Philipp Bozzini is credited with having developed the first endoscope in 1805, called the Lichtleiter (German for “light conductor”), using a candle as its light source. Adolf Kussmaul, however, developed the first rigid gastroscope in 1868, recruiting a sword-swallower in his first demonstration.


Yours truly,

Judy A. Trieu, MD, MPH
Editor-in-Chief
Advanced Endoscopy Fellow
Division of Gastroenterology & Hepatology
University of North Carolina at Chapel Hill

Dear friends,

Since the last issue of The New Gastroenterologist, the GI Fellowship Match has occurred and CONGRATULATIONS to the Class of 2026! You’ve all been on an arduous journey to get here, and it’s really time to slow down and soak up as much as you can. For those who did not match, do not give up, because you are still the future of GI!

This issue of TNG is particularly special to me, because it marks my first official selection of articles as I embark on my own TNG journey, and the theme is the future of GI. In the “In Focus” article this quarter, Dr. Eugenia N. Uche-Anya and Dr. Tyler M. Berzin review the vast and emerging advances of artificial intelligence (AI) in colonoscopy, its role in augmenting patient care, obstacles in incorporating AI into current practice, and the future of AI in gastroenterology and hepatology. One important aspect of developing our future in these technologies includes getting involved with industry. Dr. Raman Muthusamy gives practical tips on developing and navigating relationships with industry, with highlights on understanding intellectual property and conflicts of interest.

Continuing our trek into the future of GI, telemedicine came into the fold with the COVID-19 pandemic, and it is clearly here to stay. Dr. Russ R. Arjal repositions telemedicine as a way to increase access to care and optimize practice revenue, with the aim of improving patient outcomes in the future.

Last, to ground this issue clinically, Dr. Jason Kwon and Dr. Paul T. Kroner review the gastrointestinal, hepatic, and pancreaticobiliary adverse manifestations and management of immune checkpoint inhibitors, especially now that immunotherapies have revolutionized the treatment of cancer. As gastroenterologists, we are and will be seeing more and more of these adverse events.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]). You may also contact Jillian Schweitzer ([email protected]), managing editor of TNG.

Until next time, I leave you with a historical fun fact: Philipp Bozzini is credited with having developed the first endoscope in 1805, called the Lichtleiter (German for “light conductor”), using a candle as its light source. Adolf Kussmaul, however, developed the first rigid gastroscope in 1868, recruiting a sword-swallower in his first demonstration.


Yours truly,

Judy A. Trieu, MD, MPH
Editor-in-Chief
Advanced Endoscopy Fellow
Division of Gastroenterology & Hepatology
University of North Carolina at Chapel Hill

Introduction

The professional activity of physicians has traditionally consisted of patient care, teaching/education, and research in varying proportions. These aims, especially education and research, have traditionally been achieved in academic health settings. However, involvement with industry can afford all physicians an opportunity to increase patient referrals, gain exposure to colleagues through a variety of educational opportunities, and participate in meaningful research projects they could not initiate independently. This article will discuss a variety of ways that gastroenterologists can engage with industry to achieve a mutually beneficial relationship.

How to initiate relationships with industry

Here are several ways to initiate a collaboration with industry. A few of the most common ways are to become a site investigator of a multicenter device or pharmaceutical trial, participate as a member of a speaker’s bureau, or obtain training on a new technology and subsequently incorporate it into your clinical practice. To find out what trials are enrolling and looking for additional sites or new studies that are being planned, I would suggest contacting the company’s local representative and have them put you in touch the appropriate personnel in the clinical trials division. For individuals who become involved in trials, this can be a great way to improve your understanding of how to design and conduct clinical trials as well as gain exposure to colleagues with similar clinical and research interests. Some of my closest long-term collaborators and friends have been individuals who I initially met as part of industry trials at investigator meetings. Another approach is to participate in a speaker’s bureau, which can be an excellent way to improve one’s presentation skills as well as gain knowledge with respect to a specific disease state. It is also a great way to network, meet colleagues, and develop a local and regional reputation as a content expert on a specific topic. Methods to find out about such opportunities include touring the exhibit halls during educational meetings and reading scientific journals to identify new products that are launching. I have found these sorts of opportunities can significantly increase topic-based referrals. Finally, obtaining training on a new diagnostic or therapeutic technology (usually through an industry-sponsored course) can allow individuals an opportunity to offer a unique or distinctive service to their community. In addition, as further clinical expertise is gained, the relationship can be expanded to offer local, regional, or even national training courses to colleagues via either on-site or virtual courses. Similarly, opportunities to speak about or demonstrate the technology/technique at educational courses may also follow.

Navigating and expanding the relationship

Once an individual establishes a relationship with a company or has established a reputation as a key opinion leader, additional opportunities for engagement may become available. These include serving as a consultant, becoming a member of an advisory board, participating or directing educational courses for trainees/practitioners, or serving as the principal investigator of a future clinical trial. Serving as a consultant can be quite rewarding as it can highlight clinical needs, identify where product improvement can be achieved, and focus where research and development funds should be directed. Serving on the advisory board can afford an even higher level of influence where corporate strategy can be influenced. Such input is particularly impactful with smaller companies looking to enter a new field or expand a limited market share. There are also a variety of educational opportunities offered by industry including local, regional, and national courses that focus on utilizing a new technology or education concerning a specific disease state. These courses can be held locally at the physician’s clinical site or off site to attract the desired target audience. Finally, being involved in research studies, especially early-stage projects, can be critical as many small companies have limited capital, and it is essential for them to design studies with appropriate endpoints that will ideally achieve both regulatory approval as well as payor coverage. Of note, in addition to relationships directly involving industry, the American Gastroenterological Association Center for GI Innovation and Technology (CGIT) also offers the opportunity to be part of key opinion leader meetings arranged and organized by the AGA. This may allow for some individuals to participate who may be restricted from direct relationships with industry partners. The industry services offered by the CGIT also include clinical trial design and registry management services.

Entrepreneurship/intellectual property

A less commonly explored opportunity with industry involves the development of one’s own intellectual property. Some of the most impactful technologies in my advanced endoscopy clinical practice have been developed from the ideas of gastroenterology colleagues that have been successfully commercialized. These include radiofrequency ablation technology to treat Barrett’s esophagus and the development of lumen-apposing stents. There are several options for physicians with an idea for an innovation. These can include working with a university technology transfer department if they are in an academic setting, creation of their own company, or collaborating with industry to develop the device through a licensing/royalty agreement. The AGA CGIT offers extensive resources to physicians with new ideas on how to secure their intellectual property as well as to evaluate the feasibility of the aforementioned options to choose which may be most appropriate for them.

Important caveats

It is important that physicians with industry relations be aware of their local institutional policies. Some institutions may prohibit such activities while others may limit the types of relationships or the amount of income that can be received. It is the physician’s responsibility to be aware of their institution’s guidelines prior to formalizing industry agreements. If intellectual property is involved, it is essential to know the specific rules regarding physician remuneration, especially pertaining to royalty or equity agreements. Furthermore, with regard to presentations and publications, it is required to acknowledge industry relations and potential conflicts of interest. Failure to do so may adversely affect an individual’s reputation as well as lead to additional consequences such as the potential for retraction of publications or restrictions regarding future educational speaking opportunities. In addition, key opinion leaders often consult for several companies that may be in competition with each other. Therefore, it is essential that there is no disclosure of confidential proprietary information among companies. Finally, the financial incentives resulting from industry collaboration should never influence physician judgment when interpreting or speaking about data regarding product efficacy or safety.

Conclusions

In summary, there are numerous opportunities for physicians to collaborate with industry. These relationships can be very rewarding and can serve to expedite the introduction of new diagnostic or treatment modalities and provide the opportunity to network and interact with colleagues as well as to participate in important research that improves clinical practice. The nature of these relationships should always be transparent, and it is the physician’s responsibility to ensure that the types of relationships that are engaged in are permitted by their employer. Over the course of my career, I have participated in nearly all forms of these relationships and have seen that participation lead to important publications, changes in corporate strategy, the fostering of acquisitions, and the rapid development and utilization of new endoscopic technologies. It is my personal belief than industry relationships can improve professional satisfaction, enhance one’s brand, and most importantly, expedite clinical innovation to improve patient care.

Dr. Muthusamy is professor of clinical medicine at the University of California, Los Angeles, and medical director of endoscopy, UCLA Health System. He disclosed ties with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

Introduction

The professional activity of physicians has traditionally consisted of patient care, teaching/education, and research in varying proportions. These aims, especially education and research, have traditionally been achieved in academic health settings. However, involvement with industry can afford all physicians an opportunity to increase patient referrals, gain exposure to colleagues through a variety of educational opportunities, and participate in meaningful research projects they could not initiate independently. This article will discuss a variety of ways that gastroenterologists can engage with industry to achieve a mutually beneficial relationship.

How to initiate relationships with industry

Here are several ways to initiate a collaboration with industry. A few of the most common ways are to become a site investigator of a multicenter device or pharmaceutical trial, participate as a member of a speaker’s bureau, or obtain training on a new technology and subsequently incorporate it into your clinical practice. To find out what trials are enrolling and looking for additional sites or new studies that are being planned, I would suggest contacting the company’s local representative and have them put you in touch the appropriate personnel in the clinical trials division. For individuals who become involved in trials, this can be a great way to improve your understanding of how to design and conduct clinical trials as well as gain exposure to colleagues with similar clinical and research interests. Some of my closest long-term collaborators and friends have been individuals who I initially met as part of industry trials at investigator meetings. Another approach is to participate in a speaker’s bureau, which can be an excellent way to improve one’s presentation skills as well as gain knowledge with respect to a specific disease state. It is also a great way to network, meet colleagues, and develop a local and regional reputation as a content expert on a specific topic. Methods to find out about such opportunities include touring the exhibit halls during educational meetings and reading scientific journals to identify new products that are launching. I have found these sorts of opportunities can significantly increase topic-based referrals. Finally, obtaining training on a new diagnostic or therapeutic technology (usually through an industry-sponsored course) can allow individuals an opportunity to offer a unique or distinctive service to their community. In addition, as further clinical expertise is gained, the relationship can be expanded to offer local, regional, or even national training courses to colleagues via either on-site or virtual courses. Similarly, opportunities to speak about or demonstrate the technology/technique at educational courses may also follow.

Navigating and expanding the relationship

Once an individual establishes a relationship with a company or has established a reputation as a key opinion leader, additional opportunities for engagement may become available. These include serving as a consultant, becoming a member of an advisory board, participating or directing educational courses for trainees/practitioners, or serving as the principal investigator of a future clinical trial. Serving as a consultant can be quite rewarding as it can highlight clinical needs, identify where product improvement can be achieved, and focus where research and development funds should be directed. Serving on the advisory board can afford an even higher level of influence where corporate strategy can be influenced. Such input is particularly impactful with smaller companies looking to enter a new field or expand a limited market share. There are also a variety of educational opportunities offered by industry including local, regional, and national courses that focus on utilizing a new technology or education concerning a specific disease state. These courses can be held locally at the physician’s clinical site or off site to attract the desired target audience. Finally, being involved in research studies, especially early-stage projects, can be critical as many small companies have limited capital, and it is essential for them to design studies with appropriate endpoints that will ideally achieve both regulatory approval as well as payor coverage. Of note, in addition to relationships directly involving industry, the American Gastroenterological Association Center for GI Innovation and Technology (CGIT) also offers the opportunity to be part of key opinion leader meetings arranged and organized by the AGA. This may allow for some individuals to participate who may be restricted from direct relationships with industry partners. The industry services offered by the CGIT also include clinical trial design and registry management services.

Entrepreneurship/intellectual property

A less commonly explored opportunity with industry involves the development of one’s own intellectual property. Some of the most impactful technologies in my advanced endoscopy clinical practice have been developed from the ideas of gastroenterology colleagues that have been successfully commercialized. These include radiofrequency ablation technology to treat Barrett’s esophagus and the development of lumen-apposing stents. There are several options for physicians with an idea for an innovation. These can include working with a university technology transfer department if they are in an academic setting, creation of their own company, or collaborating with industry to develop the device through a licensing/royalty agreement. The AGA CGIT offers extensive resources to physicians with new ideas on how to secure their intellectual property as well as to evaluate the feasibility of the aforementioned options to choose which may be most appropriate for them.

Important caveats

It is important that physicians with industry relations be aware of their local institutional policies. Some institutions may prohibit such activities while others may limit the types of relationships or the amount of income that can be received. It is the physician’s responsibility to be aware of their institution’s guidelines prior to formalizing industry agreements. If intellectual property is involved, it is essential to know the specific rules regarding physician remuneration, especially pertaining to royalty or equity agreements. Furthermore, with regard to presentations and publications, it is required to acknowledge industry relations and potential conflicts of interest. Failure to do so may adversely affect an individual’s reputation as well as lead to additional consequences such as the potential for retraction of publications or restrictions regarding future educational speaking opportunities. In addition, key opinion leaders often consult for several companies that may be in competition with each other. Therefore, it is essential that there is no disclosure of confidential proprietary information among companies. Finally, the financial incentives resulting from industry collaboration should never influence physician judgment when interpreting or speaking about data regarding product efficacy or safety.

Conclusions

In summary, there are numerous opportunities for physicians to collaborate with industry. These relationships can be very rewarding and can serve to expedite the introduction of new diagnostic or treatment modalities and provide the opportunity to network and interact with colleagues as well as to participate in important research that improves clinical practice. The nature of these relationships should always be transparent, and it is the physician’s responsibility to ensure that the types of relationships that are engaged in are permitted by their employer. Over the course of my career, I have participated in nearly all forms of these relationships and have seen that participation lead to important publications, changes in corporate strategy, the fostering of acquisitions, and the rapid development and utilization of new endoscopic technologies. It is my personal belief than industry relationships can improve professional satisfaction, enhance one’s brand, and most importantly, expedite clinical innovation to improve patient care.

Dr. Muthusamy is professor of clinical medicine at the University of California, Los Angeles, and medical director of endoscopy, UCLA Health System. He disclosed ties with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

Introduction

The professional activity of physicians has traditionally consisted of patient care, teaching/education, and research in varying proportions. These aims, especially education and research, have traditionally been achieved in academic health settings. However, involvement with industry can afford all physicians an opportunity to increase patient referrals, gain exposure to colleagues through a variety of educational opportunities, and participate in meaningful research projects they could not initiate independently. This article will discuss a variety of ways that gastroenterologists can engage with industry to achieve a mutually beneficial relationship.

How to initiate relationships with industry

Here are several ways to initiate a collaboration with industry. A few of the most common ways are to become a site investigator of a multicenter device or pharmaceutical trial, participate as a member of a speaker’s bureau, or obtain training on a new technology and subsequently incorporate it into your clinical practice. To find out what trials are enrolling and looking for additional sites or new studies that are being planned, I would suggest contacting the company’s local representative and have them put you in touch the appropriate personnel in the clinical trials division. For individuals who become involved in trials, this can be a great way to improve your understanding of how to design and conduct clinical trials as well as gain exposure to colleagues with similar clinical and research interests. Some of my closest long-term collaborators and friends have been individuals who I initially met as part of industry trials at investigator meetings. Another approach is to participate in a speaker’s bureau, which can be an excellent way to improve one’s presentation skills as well as gain knowledge with respect to a specific disease state. It is also a great way to network, meet colleagues, and develop a local and regional reputation as a content expert on a specific topic. Methods to find out about such opportunities include touring the exhibit halls during educational meetings and reading scientific journals to identify new products that are launching. I have found these sorts of opportunities can significantly increase topic-based referrals. Finally, obtaining training on a new diagnostic or therapeutic technology (usually through an industry-sponsored course) can allow individuals an opportunity to offer a unique or distinctive service to their community. In addition, as further clinical expertise is gained, the relationship can be expanded to offer local, regional, or even national training courses to colleagues via either on-site or virtual courses. Similarly, opportunities to speak about or demonstrate the technology/technique at educational courses may also follow.

Navigating and expanding the relationship

Once an individual establishes a relationship with a company or has established a reputation as a key opinion leader, additional opportunities for engagement may become available. These include serving as a consultant, becoming a member of an advisory board, participating or directing educational courses for trainees/practitioners, or serving as the principal investigator of a future clinical trial. Serving as a consultant can be quite rewarding as it can highlight clinical needs, identify where product improvement can be achieved, and focus where research and development funds should be directed. Serving on the advisory board can afford an even higher level of influence where corporate strategy can be influenced. Such input is particularly impactful with smaller companies looking to enter a new field or expand a limited market share. There are also a variety of educational opportunities offered by industry including local, regional, and national courses that focus on utilizing a new technology or education concerning a specific disease state. These courses can be held locally at the physician’s clinical site or off site to attract the desired target audience. Finally, being involved in research studies, especially early-stage projects, can be critical as many small companies have limited capital, and it is essential for them to design studies with appropriate endpoints that will ideally achieve both regulatory approval as well as payor coverage. Of note, in addition to relationships directly involving industry, the American Gastroenterological Association Center for GI Innovation and Technology (CGIT) also offers the opportunity to be part of key opinion leader meetings arranged and organized by the AGA. This may allow for some individuals to participate who may be restricted from direct relationships with industry partners. The industry services offered by the CGIT also include clinical trial design and registry management services.

Entrepreneurship/intellectual property

A less commonly explored opportunity with industry involves the development of one’s own intellectual property. Some of the most impactful technologies in my advanced endoscopy clinical practice have been developed from the ideas of gastroenterology colleagues that have been successfully commercialized. These include radiofrequency ablation technology to treat Barrett’s esophagus and the development of lumen-apposing stents. There are several options for physicians with an idea for an innovation. These can include working with a university technology transfer department if they are in an academic setting, creation of their own company, or collaborating with industry to develop the device through a licensing/royalty agreement. The AGA CGIT offers extensive resources to physicians with new ideas on how to secure their intellectual property as well as to evaluate the feasibility of the aforementioned options to choose which may be most appropriate for them.

Important caveats

It is important that physicians with industry relations be aware of their local institutional policies. Some institutions may prohibit such activities while others may limit the types of relationships or the amount of income that can be received. It is the physician’s responsibility to be aware of their institution’s guidelines prior to formalizing industry agreements. If intellectual property is involved, it is essential to know the specific rules regarding physician remuneration, especially pertaining to royalty or equity agreements. Furthermore, with regard to presentations and publications, it is required to acknowledge industry relations and potential conflicts of interest. Failure to do so may adversely affect an individual’s reputation as well as lead to additional consequences such as the potential for retraction of publications or restrictions regarding future educational speaking opportunities. In addition, key opinion leaders often consult for several companies that may be in competition with each other. Therefore, it is essential that there is no disclosure of confidential proprietary information among companies. Finally, the financial incentives resulting from industry collaboration should never influence physician judgment when interpreting or speaking about data regarding product efficacy or safety.

Conclusions

In summary, there are numerous opportunities for physicians to collaborate with industry. These relationships can be very rewarding and can serve to expedite the introduction of new diagnostic or treatment modalities and provide the opportunity to network and interact with colleagues as well as to participate in important research that improves clinical practice. The nature of these relationships should always be transparent, and it is the physician’s responsibility to ensure that the types of relationships that are engaged in are permitted by their employer. Over the course of my career, I have participated in nearly all forms of these relationships and have seen that participation lead to important publications, changes in corporate strategy, the fostering of acquisitions, and the rapid development and utilization of new endoscopic technologies. It is my personal belief than industry relationships can improve professional satisfaction, enhance one’s brand, and most importantly, expedite clinical innovation to improve patient care.

Dr. Muthusamy is professor of clinical medicine at the University of California, Los Angeles, and medical director of endoscopy, UCLA Health System. He disclosed ties with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

Considerable advances in artificial intelligence (AI) and machine-learning (ML) methodologies have led to the emergence of promising tools in the field of gastrointestinal endoscopy. Computer vision is an application of AI/ML that has been successfully applied for the computer-aided detection (CADe) and computer-aided diagnosis (CADx) of colon polyps and numerous other conditions encountered during GI endoscopy. Outside of computer vision, a wide variety of other AI applications have been applied to gastroenterology, ranging from natural language processing (NLP) to optimize clinical documentation and endoscopy quality reporting to ML techniques that predict disease severity/treatment response and augment clinical decision-making. This article focuses on opportunities for AI applications in colonoscopy, reviews the existing data, describes the challenges limiting widespread adoption, and explores future directions.

In the United States, colonoscopy is the standard for colon cancer screening and prevention; however, precancerous polyps can be missed for various reasons, ranging from subtle surface appearance of the polyp or location behind a colonic fold to operator-dependent reasons such as inadequate mucosal inspection. Though clinical practice guidelines have set adenoma detection rate (ADR) thresholds at 20% for women and 30% for men, studies have shown a 4- to 10-fold variation in ADR among physicians in clinical practice settings^,1 with an estimated adenoma miss rate (AMR) of 25% and a false-negative colonoscopy rate of 12%.² Variability in adenoma detection affects the risk of interval colorectal cancer post colonoscopy.^3,4

AI provides an opportunity for mitigating this risk. Advances in deep learning and computer vision have led to the development of CADe systems that automatically detect polyps in real time during colonoscopy, resulting in reduced adenoma miss rates (Table 1). In addition to polyp detection, deep-learning technologies are also being used in CADx systems for polyp diagnosis and characterization of malignancy risk. This could aid therapeutic decision-making: Unnecessary resection or histopathologic analysis could be obviated for benign hyperplastic polyps. On the other end of the polyp spectrum, an AI tool that could predict the presence or absence of submucosal invasion could be a powerful tool when evaluating early colon cancers for consideration of endoscopic submucosal dissection vs. surgery. Examples of CADe polyp detection and CADx polyp characterization are shown in Figure 1.

Other potential computer vision applications that may improve colonoscopy quality include tools that help measure adequacy of mucosal exposure, segmental inspection time, and a variety of other parameters associated with polyp detection performance. These are promising areas for future research. Beyond improving colonoscopy technique, natural language processing tools already are being used to optimize clinical documentation as well as extract information from colonoscopy and pathology reports that can facilitate reporting of colonoscopy quality metrics such as ADR, cecal intubation rate, withdrawal time, and bowel preparation adequacy. AI-powered analytics may help unlock large-scale reporting of colonoscopy quality metrics on a health-systems level⁵ or population-level,⁶ helping to ensure optimal performance and identifying avenues for colonoscopy quality improvement.

In comparison, the data landscape for CADx is nascent and currently limited to several retrospective studies dating back to 2009 and a few prospective studies that have shown promising results.^10,11 There is an expectation that integrated CADx also may support the adoption of “resect and discard” or “diagnose and leave” strategies for low-risk polyps. About two-thirds of polyps identified on average-risk screening colonoscopies are diminutive polyps (less than 5 mm in size), which rarely have advanced histologic features (about 0.5%) and are sometimes non-neoplastic (30%). Malignancy risk is even lower in the distal colon.¹² As routine histopathologic assessment of such polyps is mostly of limited clinical utility and comes with added pathology costs, CADx technologies may offer a more cost-effective approach where polyps that are characterized in real-time as low-risk adenomas or non-neoplastic are “resected and discarded” or “left in” respectively. In 2011, prior to the development of current AI tools, the American Society for Gastrointestinal Endoscopy set performance thresholds for technologies supporting real-time endoscopic assessment of the histology of diminutive colorectal polyps. The ASGE recommended 90% histopathologic concordance for “resect and discard” tools and 90% negative predictive value for adenomatous histology for “diagnose and leave,” tools.¹³ Narrow-band imaging (NBI), for example, has been shown to meet these benchmarks^14,15 with a modeling study suggesting that implementing “resect and discard” strategies with such tools could result in annual savings of $33 million without adversely affecting efficacy, although practical adoption has been limited.¹⁶ More recent work has directly explored the feasibility of leveraging CADx to support “leave-in-situ” and “resect-and-discard” strategies.¹⁷

Similarly, while CADe use in colonoscopy is associated with additional up-front costs, a modeling study suggests that its associated gains in ADR (as detailed in Table 1) make it a cost-saving strategy for colorectal cancer prevention in the long term.¹⁸ There is still uncertainty on whether the incremental CADe-associated gains in adenoma detection will necessarily translate to significant reductions in interval colorectal cancer risk, particularly for endoscopists who are already high-performing polyp detectors. A recent study suggests that, although higher ADRs were associated with lower rates of interval colorectal cancer, the gains in interval colorectal cancer risk reduction appeared to level off with ADRs above 35%-40% (this finding may be limited by statistical power).¹⁹ Further, most of the data from CADe trials suggest that gains in adenoma detection are not driven by increased detection of advanced lesions with high malignancy risk but by small polyps with long latency periods of about 5-10 years, which may not significantly alter interval cancer risk. It remains to be determined whether adoption of CADe will have an impact on hard outcomes, most importantly interval colorectal cancer risk, or merely result in increased resource utilization without moving the needle on colorectal cancer prevention. To answer this question, the OperA study – a large-scale randomized clinical trial of 200,000 patients across 18 centers from 13 countries – was launched in 2022. It will investigate the effect of colonoscopy with CADe on a number of critical measures, including long-term interval colon cancer risk.²⁰

Despite commercial availability of regulatory-approved CADe systems and data supporting use for adenoma detection in colonoscopy, mainstream adoption in clinical practice has been sluggish. Physician survey studies have shown that, although there is considerable interest in integrating CADe into clinical practice, there are concerns about access, cost and reimbursement, integration into clinical work-flow, increased procedural times, over-reliance on AI, and algorithmic bias leading to errors.^21,22 In addition, without mandatory requirements for ADR reporting or clinical practice guideline recommendations for CADe use, these systems may not be perceived as valuable or ready for prime time even though the evidence suggests otherwise.^23,24 For CADe systems to see widespread adoption in clinical practice, it is important that future research studies rigorously investigate and characterize these potential barriers to better inform strategies to address AI hesitancy and implementation challenges. Such efforts can provide an integration framework for future AI applications in gastroenterology beyond colonoscopy, such as CADe of esophageal and gastric premalignant lesions in upper endoscopy, CADx for pancreatic cysts and liver lesions on imaging, NLP tools to optimizing efficient clinical documentation and reporting, and many others.

Dr. Uche-Anya is in the division of gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Berzin is with the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Dr. Berzin is a consultant for Wision AI, Medtronic, Magentiq Eye, RSIP Vision, and Docbot.

Corresponding Author: Eugenia Uche-Anya [email protected] Twitter: @UcheAnyaMD @tberzin

References

1. Corley DA et al. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc. Sep 2011;74(3):656-65. doi: 10.1016/j.gie.2011.04.017.

2. Zhao S et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 05 2019;156(6):1661-74.e11. doi: 10.1053/j.gastro.2019.01.260.

3. Kaminski MF et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. May 13 2010;362(19):1795-803. doi: 10.1056/NEJMoa0907667.

4. Corley DA et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. Apr 03 2014;370(14):1298-306. doi: 10.1056/NEJMoa1309086.

5. Laique SN et al. Application of optical character recognition with natural language processing for large-scale quality metric data extraction in colonoscopy reports. Gastrointest Endosc. 03 2021;93(3):750-7. doi: 10.1016/j.gie.2020.08.038.

6. Tinmouth J et al. Validation of a natural language processing algorithm to identify adenomas and measure adenoma detection rates across a health system: a population-level study. Gastrointest Endosc. Jul 14 2022. doi: 10.1016/j.gie.2022.07.009.

7. Glissen Brown JR et al. Deep learning computer-aided polyp detection reduces adenoma miss rate: A United States multi-center randomized tandem colonoscopy study (CADeT-CS Trial). Clin Gastroenterol Hepatol. 07 2022;20(7):1499-1507.e4. doi: 10.1016/j.cgh.2021.09.009.

8. Wallace MB et al. Impact of artificial intelligence on miss rate of colorectal neoplasia. Gastroenterology. 07 2022;163(1):295-304.e5. doi: 10.1053/j.gastro.2022.03.007.

9. Hassan C et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc. 01 2021;93(1):77-85.e6. doi: 10.1016/j.gie.2020.06.059.

10. Glissen Brown JR and Berzin TM. Adoption of new technologies: Artificial intelligence. Gastrointest Endosc Clin N Am. Oct 2021;31(4):743-58. doi: 10.1016/j.giec.2021.05.010.

11. Larsen SLV and Mori Y. Artificial intelligence in colonoscopy: A review on the current status. DEN open. Apr 2022;2(1):e109. doi: 10.1002/deo2.109.

12. Gupta N et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. May 2012;75(5):1022-30. doi: 10.1016/j.gie.2012.01.020.

13. Rex DK et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2011;73(3):419-22. doi: 10.1016/j.gie.2011.01.023.

14. Abu Dayyeh BK et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e1-16. doi: 10.1016/j.gie.2014.12.022.

15. Mori Y et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: A prospective study. Ann Intern Med. Sep 18 2018;169(6):357-66. doi: 10.7326/M18-0249.

16. Hassan C et al.. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. Oct 2010;8(10):865-9, 869.e1-3. doi: 10.1016/j.cgh.2010.05.018.

17. Hassan C et al. Artificial intelligence allows leaving-in-situ colorectal polyps. Clin Gastroenterol Hepatol. Nov 2022;20(11):2505-13.e4. doi: 10.1016/j.cgh.2022.04.045.

18. Areia M et al. Cost-effectiveness of artificial intelligence for screening colonoscopy: a modelling study. Lancet Digit Health. 06 2022;4(6):e436-44. doi: 10.1016/S2589-7500(22)00042-5.

19. Schottinger JE et al. Association of physician adenoma detection rates with postcolonoscopy colorectal cancer. JAMA. 2022 Jun 7;327(21):2114-22. doi: 10.1001/jama.2022.6644.

20. Oslo Uo. Optimising colorectal cancer prevention through personalised treatment with artificial intelligence. 2022.

21. Wadhwa V et al. Physician sentiment toward artificial intelligence (AI) in colonoscopic practice: a survey of US gastroenterologists. Endosc Int Open. Oct 2020;8(10):E1379-84. doi: 10.1055/a-1223-1926.

22. Kader R et al. Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence. Frontline Gastroenterol. 2022;13(5):423-9. doi: 10.1136/flgastro-2021-101994.

23. Rex DKet al. Artificial intelligence improves detection at colonoscopy: Why aren’t we all already using it? Gastroenterology. 07 2022;163(1):35-7. doi: 10.1053/j.gastro.2022.04.042.

24. Ahmad OF et al. Establishing key research questions for the implementation of artificial intelligence in colonoscopy: A modified Delphi method. Endoscopy. 09 2021;53(9):893-901. doi: 10.1055/a-1306-7590

Considerable advances in artificial intelligence (AI) and machine-learning (ML) methodologies have led to the emergence of promising tools in the field of gastrointestinal endoscopy. Computer vision is an application of AI/ML that has been successfully applied for the computer-aided detection (CADe) and computer-aided diagnosis (CADx) of colon polyps and numerous other conditions encountered during GI endoscopy. Outside of computer vision, a wide variety of other AI applications have been applied to gastroenterology, ranging from natural language processing (NLP) to optimize clinical documentation and endoscopy quality reporting to ML techniques that predict disease severity/treatment response and augment clinical decision-making. This article focuses on opportunities for AI applications in colonoscopy, reviews the existing data, describes the challenges limiting widespread adoption, and explores future directions.

In the United States, colonoscopy is the standard for colon cancer screening and prevention; however, precancerous polyps can be missed for various reasons, ranging from subtle surface appearance of the polyp or location behind a colonic fold to operator-dependent reasons such as inadequate mucosal inspection. Though clinical practice guidelines have set adenoma detection rate (ADR) thresholds at 20% for women and 30% for men, studies have shown a 4- to 10-fold variation in ADR among physicians in clinical practice settings^,1 with an estimated adenoma miss rate (AMR) of 25% and a false-negative colonoscopy rate of 12%.² Variability in adenoma detection affects the risk of interval colorectal cancer post colonoscopy.^3,4

AI provides an opportunity for mitigating this risk. Advances in deep learning and computer vision have led to the development of CADe systems that automatically detect polyps in real time during colonoscopy, resulting in reduced adenoma miss rates (Table 1). In addition to polyp detection, deep-learning technologies are also being used in CADx systems for polyp diagnosis and characterization of malignancy risk. This could aid therapeutic decision-making: Unnecessary resection or histopathologic analysis could be obviated for benign hyperplastic polyps. On the other end of the polyp spectrum, an AI tool that could predict the presence or absence of submucosal invasion could be a powerful tool when evaluating early colon cancers for consideration of endoscopic submucosal dissection vs. surgery. Examples of CADe polyp detection and CADx polyp characterization are shown in Figure 1.

Other potential computer vision applications that may improve colonoscopy quality include tools that help measure adequacy of mucosal exposure, segmental inspection time, and a variety of other parameters associated with polyp detection performance. These are promising areas for future research. Beyond improving colonoscopy technique, natural language processing tools already are being used to optimize clinical documentation as well as extract information from colonoscopy and pathology reports that can facilitate reporting of colonoscopy quality metrics such as ADR, cecal intubation rate, withdrawal time, and bowel preparation adequacy. AI-powered analytics may help unlock large-scale reporting of colonoscopy quality metrics on a health-systems level⁵ or population-level,⁶ helping to ensure optimal performance and identifying avenues for colonoscopy quality improvement.

In comparison, the data landscape for CADx is nascent and currently limited to several retrospective studies dating back to 2009 and a few prospective studies that have shown promising results.^10,11 There is an expectation that integrated CADx also may support the adoption of “resect and discard” or “diagnose and leave” strategies for low-risk polyps. About two-thirds of polyps identified on average-risk screening colonoscopies are diminutive polyps (less than 5 mm in size), which rarely have advanced histologic features (about 0.5%) and are sometimes non-neoplastic (30%). Malignancy risk is even lower in the distal colon.¹² As routine histopathologic assessment of such polyps is mostly of limited clinical utility and comes with added pathology costs, CADx technologies may offer a more cost-effective approach where polyps that are characterized in real-time as low-risk adenomas or non-neoplastic are “resected and discarded” or “left in” respectively. In 2011, prior to the development of current AI tools, the American Society for Gastrointestinal Endoscopy set performance thresholds for technologies supporting real-time endoscopic assessment of the histology of diminutive colorectal polyps. The ASGE recommended 90% histopathologic concordance for “resect and discard” tools and 90% negative predictive value for adenomatous histology for “diagnose and leave,” tools.¹³ Narrow-band imaging (NBI), for example, has been shown to meet these benchmarks^14,15 with a modeling study suggesting that implementing “resect and discard” strategies with such tools could result in annual savings of $33 million without adversely affecting efficacy, although practical adoption has been limited.¹⁶ More recent work has directly explored the feasibility of leveraging CADx to support “leave-in-situ” and “resect-and-discard” strategies.¹⁷

Similarly, while CADe use in colonoscopy is associated with additional up-front costs, a modeling study suggests that its associated gains in ADR (as detailed in Table 1) make it a cost-saving strategy for colorectal cancer prevention in the long term.¹⁸ There is still uncertainty on whether the incremental CADe-associated gains in adenoma detection will necessarily translate to significant reductions in interval colorectal cancer risk, particularly for endoscopists who are already high-performing polyp detectors. A recent study suggests that, although higher ADRs were associated with lower rates of interval colorectal cancer, the gains in interval colorectal cancer risk reduction appeared to level off with ADRs above 35%-40% (this finding may be limited by statistical power).¹⁹ Further, most of the data from CADe trials suggest that gains in adenoma detection are not driven by increased detection of advanced lesions with high malignancy risk but by small polyps with long latency periods of about 5-10 years, which may not significantly alter interval cancer risk. It remains to be determined whether adoption of CADe will have an impact on hard outcomes, most importantly interval colorectal cancer risk, or merely result in increased resource utilization without moving the needle on colorectal cancer prevention. To answer this question, the OperA study – a large-scale randomized clinical trial of 200,000 patients across 18 centers from 13 countries – was launched in 2022. It will investigate the effect of colonoscopy with CADe on a number of critical measures, including long-term interval colon cancer risk.²⁰

Despite commercial availability of regulatory-approved CADe systems and data supporting use for adenoma detection in colonoscopy, mainstream adoption in clinical practice has been sluggish. Physician survey studies have shown that, although there is considerable interest in integrating CADe into clinical practice, there are concerns about access, cost and reimbursement, integration into clinical work-flow, increased procedural times, over-reliance on AI, and algorithmic bias leading to errors.^21,22 In addition, without mandatory requirements for ADR reporting or clinical practice guideline recommendations for CADe use, these systems may not be perceived as valuable or ready for prime time even though the evidence suggests otherwise.^23,24 For CADe systems to see widespread adoption in clinical practice, it is important that future research studies rigorously investigate and characterize these potential barriers to better inform strategies to address AI hesitancy and implementation challenges. Such efforts can provide an integration framework for future AI applications in gastroenterology beyond colonoscopy, such as CADe of esophageal and gastric premalignant lesions in upper endoscopy, CADx for pancreatic cysts and liver lesions on imaging, NLP tools to optimizing efficient clinical documentation and reporting, and many others.

Dr. Uche-Anya is in the division of gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Berzin is with the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Dr. Berzin is a consultant for Wision AI, Medtronic, Magentiq Eye, RSIP Vision, and Docbot.

Corresponding Author: Eugenia Uche-Anya [email protected] Twitter: @UcheAnyaMD @tberzin

References

1. Corley DA et al. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc. Sep 2011;74(3):656-65. doi: 10.1016/j.gie.2011.04.017.

2. Zhao S et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 05 2019;156(6):1661-74.e11. doi: 10.1053/j.gastro.2019.01.260.

3. Kaminski MF et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. May 13 2010;362(19):1795-803. doi: 10.1056/NEJMoa0907667.

4. Corley DA et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. Apr 03 2014;370(14):1298-306. doi: 10.1056/NEJMoa1309086.

5. Laique SN et al. Application of optical character recognition with natural language processing for large-scale quality metric data extraction in colonoscopy reports. Gastrointest Endosc. 03 2021;93(3):750-7. doi: 10.1016/j.gie.2020.08.038.

6. Tinmouth J et al. Validation of a natural language processing algorithm to identify adenomas and measure adenoma detection rates across a health system: a population-level study. Gastrointest Endosc. Jul 14 2022. doi: 10.1016/j.gie.2022.07.009.

7. Glissen Brown JR et al. Deep learning computer-aided polyp detection reduces adenoma miss rate: A United States multi-center randomized tandem colonoscopy study (CADeT-CS Trial). Clin Gastroenterol Hepatol. 07 2022;20(7):1499-1507.e4. doi: 10.1016/j.cgh.2021.09.009.

8. Wallace MB et al. Impact of artificial intelligence on miss rate of colorectal neoplasia. Gastroenterology. 07 2022;163(1):295-304.e5. doi: 10.1053/j.gastro.2022.03.007.

9. Hassan C et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc. 01 2021;93(1):77-85.e6. doi: 10.1016/j.gie.2020.06.059.

10. Glissen Brown JR and Berzin TM. Adoption of new technologies: Artificial intelligence. Gastrointest Endosc Clin N Am. Oct 2021;31(4):743-58. doi: 10.1016/j.giec.2021.05.010.

11. Larsen SLV and Mori Y. Artificial intelligence in colonoscopy: A review on the current status. DEN open. Apr 2022;2(1):e109. doi: 10.1002/deo2.109.

12. Gupta N et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. May 2012;75(5):1022-30. doi: 10.1016/j.gie.2012.01.020.

13. Rex DK et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2011;73(3):419-22. doi: 10.1016/j.gie.2011.01.023.

14. Abu Dayyeh BK et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e1-16. doi: 10.1016/j.gie.2014.12.022.

15. Mori Y et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: A prospective study. Ann Intern Med. Sep 18 2018;169(6):357-66. doi: 10.7326/M18-0249.

16. Hassan C et al.. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. Oct 2010;8(10):865-9, 869.e1-3. doi: 10.1016/j.cgh.2010.05.018.

17. Hassan C et al. Artificial intelligence allows leaving-in-situ colorectal polyps. Clin Gastroenterol Hepatol. Nov 2022;20(11):2505-13.e4. doi: 10.1016/j.cgh.2022.04.045.

18. Areia M et al. Cost-effectiveness of artificial intelligence for screening colonoscopy: a modelling study. Lancet Digit Health. 06 2022;4(6):e436-44. doi: 10.1016/S2589-7500(22)00042-5.

19. Schottinger JE et al. Association of physician adenoma detection rates with postcolonoscopy colorectal cancer. JAMA. 2022 Jun 7;327(21):2114-22. doi: 10.1001/jama.2022.6644.

20. Oslo Uo. Optimising colorectal cancer prevention through personalised treatment with artificial intelligence. 2022.

21. Wadhwa V et al. Physician sentiment toward artificial intelligence (AI) in colonoscopic practice: a survey of US gastroenterologists. Endosc Int Open. Oct 2020;8(10):E1379-84. doi: 10.1055/a-1223-1926.

22. Kader R et al. Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence. Frontline Gastroenterol. 2022;13(5):423-9. doi: 10.1136/flgastro-2021-101994.

23. Rex DKet al. Artificial intelligence improves detection at colonoscopy: Why aren’t we all already using it? Gastroenterology. 07 2022;163(1):35-7. doi: 10.1053/j.gastro.2022.04.042.

24. Ahmad OF et al. Establishing key research questions for the implementation of artificial intelligence in colonoscopy: A modified Delphi method. Endoscopy. 09 2021;53(9):893-901. doi: 10.1055/a-1306-7590

Considerable advances in artificial intelligence (AI) and machine-learning (ML) methodologies have led to the emergence of promising tools in the field of gastrointestinal endoscopy. Computer vision is an application of AI/ML that has been successfully applied for the computer-aided detection (CADe) and computer-aided diagnosis (CADx) of colon polyps and numerous other conditions encountered during GI endoscopy. Outside of computer vision, a wide variety of other AI applications have been applied to gastroenterology, ranging from natural language processing (NLP) to optimize clinical documentation and endoscopy quality reporting to ML techniques that predict disease severity/treatment response and augment clinical decision-making. This article focuses on opportunities for AI applications in colonoscopy, reviews the existing data, describes the challenges limiting widespread adoption, and explores future directions.

In the United States, colonoscopy is the standard for colon cancer screening and prevention; however, precancerous polyps can be missed for various reasons, ranging from subtle surface appearance of the polyp or location behind a colonic fold to operator-dependent reasons such as inadequate mucosal inspection. Though clinical practice guidelines have set adenoma detection rate (ADR) thresholds at 20% for women and 30% for men, studies have shown a 4- to 10-fold variation in ADR among physicians in clinical practice settings^,1 with an estimated adenoma miss rate (AMR) of 25% and a false-negative colonoscopy rate of 12%.² Variability in adenoma detection affects the risk of interval colorectal cancer post colonoscopy.^3,4

AI provides an opportunity for mitigating this risk. Advances in deep learning and computer vision have led to the development of CADe systems that automatically detect polyps in real time during colonoscopy, resulting in reduced adenoma miss rates (Table 1). In addition to polyp detection, deep-learning technologies are also being used in CADx systems for polyp diagnosis and characterization of malignancy risk. This could aid therapeutic decision-making: Unnecessary resection or histopathologic analysis could be obviated for benign hyperplastic polyps. On the other end of the polyp spectrum, an AI tool that could predict the presence or absence of submucosal invasion could be a powerful tool when evaluating early colon cancers for consideration of endoscopic submucosal dissection vs. surgery. Examples of CADe polyp detection and CADx polyp characterization are shown in Figure 1.

Other potential computer vision applications that may improve colonoscopy quality include tools that help measure adequacy of mucosal exposure, segmental inspection time, and a variety of other parameters associated with polyp detection performance. These are promising areas for future research. Beyond improving colonoscopy technique, natural language processing tools already are being used to optimize clinical documentation as well as extract information from colonoscopy and pathology reports that can facilitate reporting of colonoscopy quality metrics such as ADR, cecal intubation rate, withdrawal time, and bowel preparation adequacy. AI-powered analytics may help unlock large-scale reporting of colonoscopy quality metrics on a health-systems level⁵ or population-level,⁶ helping to ensure optimal performance and identifying avenues for colonoscopy quality improvement.

In comparison, the data landscape for CADx is nascent and currently limited to several retrospective studies dating back to 2009 and a few prospective studies that have shown promising results.^10,11 There is an expectation that integrated CADx also may support the adoption of “resect and discard” or “diagnose and leave” strategies for low-risk polyps. About two-thirds of polyps identified on average-risk screening colonoscopies are diminutive polyps (less than 5 mm in size), which rarely have advanced histologic features (about 0.5%) and are sometimes non-neoplastic (30%). Malignancy risk is even lower in the distal colon.¹² As routine histopathologic assessment of such polyps is mostly of limited clinical utility and comes with added pathology costs, CADx technologies may offer a more cost-effective approach where polyps that are characterized in real-time as low-risk adenomas or non-neoplastic are “resected and discarded” or “left in” respectively. In 2011, prior to the development of current AI tools, the American Society for Gastrointestinal Endoscopy set performance thresholds for technologies supporting real-time endoscopic assessment of the histology of diminutive colorectal polyps. The ASGE recommended 90% histopathologic concordance for “resect and discard” tools and 90% negative predictive value for adenomatous histology for “diagnose and leave,” tools.¹³ Narrow-band imaging (NBI), for example, has been shown to meet these benchmarks^14,15 with a modeling study suggesting that implementing “resect and discard” strategies with such tools could result in annual savings of $33 million without adversely affecting efficacy, although practical adoption has been limited.¹⁶ More recent work has directly explored the feasibility of leveraging CADx to support “leave-in-situ” and “resect-and-discard” strategies.¹⁷

Similarly, while CADe use in colonoscopy is associated with additional up-front costs, a modeling study suggests that its associated gains in ADR (as detailed in Table 1) make it a cost-saving strategy for colorectal cancer prevention in the long term.¹⁸ There is still uncertainty on whether the incremental CADe-associated gains in adenoma detection will necessarily translate to significant reductions in interval colorectal cancer risk, particularly for endoscopists who are already high-performing polyp detectors. A recent study suggests that, although higher ADRs were associated with lower rates of interval colorectal cancer, the gains in interval colorectal cancer risk reduction appeared to level off with ADRs above 35%-40% (this finding may be limited by statistical power).¹⁹ Further, most of the data from CADe trials suggest that gains in adenoma detection are not driven by increased detection of advanced lesions with high malignancy risk but by small polyps with long latency periods of about 5-10 years, which may not significantly alter interval cancer risk. It remains to be determined whether adoption of CADe will have an impact on hard outcomes, most importantly interval colorectal cancer risk, or merely result in increased resource utilization without moving the needle on colorectal cancer prevention. To answer this question, the OperA study – a large-scale randomized clinical trial of 200,000 patients across 18 centers from 13 countries – was launched in 2022. It will investigate the effect of colonoscopy with CADe on a number of critical measures, including long-term interval colon cancer risk.²⁰

Despite commercial availability of regulatory-approved CADe systems and data supporting use for adenoma detection in colonoscopy, mainstream adoption in clinical practice has been sluggish. Physician survey studies have shown that, although there is considerable interest in integrating CADe into clinical practice, there are concerns about access, cost and reimbursement, integration into clinical work-flow, increased procedural times, over-reliance on AI, and algorithmic bias leading to errors.^21,22 In addition, without mandatory requirements for ADR reporting or clinical practice guideline recommendations for CADe use, these systems may not be perceived as valuable or ready for prime time even though the evidence suggests otherwise.^23,24 For CADe systems to see widespread adoption in clinical practice, it is important that future research studies rigorously investigate and characterize these potential barriers to better inform strategies to address AI hesitancy and implementation challenges. Such efforts can provide an integration framework for future AI applications in gastroenterology beyond colonoscopy, such as CADe of esophageal and gastric premalignant lesions in upper endoscopy, CADx for pancreatic cysts and liver lesions on imaging, NLP tools to optimizing efficient clinical documentation and reporting, and many others.

Dr. Uche-Anya is in the division of gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston. Dr. Berzin is with the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Dr. Berzin is a consultant for Wision AI, Medtronic, Magentiq Eye, RSIP Vision, and Docbot.

Corresponding Author: Eugenia Uche-Anya [email protected] Twitter: @UcheAnyaMD @tberzin

References

1. Corley DA et al. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc. Sep 2011;74(3):656-65. doi: 10.1016/j.gie.2011.04.017.

2. Zhao S et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 05 2019;156(6):1661-74.e11. doi: 10.1053/j.gastro.2019.01.260.

3. Kaminski MF et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. May 13 2010;362(19):1795-803. doi: 10.1056/NEJMoa0907667.

4. Corley DA et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. Apr 03 2014;370(14):1298-306. doi: 10.1056/NEJMoa1309086.

5. Laique SN et al. Application of optical character recognition with natural language processing for large-scale quality metric data extraction in colonoscopy reports. Gastrointest Endosc. 03 2021;93(3):750-7. doi: 10.1016/j.gie.2020.08.038.

6. Tinmouth J et al. Validation of a natural language processing algorithm to identify adenomas and measure adenoma detection rates across a health system: a population-level study. Gastrointest Endosc. Jul 14 2022. doi: 10.1016/j.gie.2022.07.009.

7. Glissen Brown JR et al. Deep learning computer-aided polyp detection reduces adenoma miss rate: A United States multi-center randomized tandem colonoscopy study (CADeT-CS Trial). Clin Gastroenterol Hepatol. 07 2022;20(7):1499-1507.e4. doi: 10.1016/j.cgh.2021.09.009.

8. Wallace MB et al. Impact of artificial intelligence on miss rate of colorectal neoplasia. Gastroenterology. 07 2022;163(1):295-304.e5. doi: 10.1053/j.gastro.2022.03.007.

9. Hassan C et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc. 01 2021;93(1):77-85.e6. doi: 10.1016/j.gie.2020.06.059.

10. Glissen Brown JR and Berzin TM. Adoption of new technologies: Artificial intelligence. Gastrointest Endosc Clin N Am. Oct 2021;31(4):743-58. doi: 10.1016/j.giec.2021.05.010.

11. Larsen SLV and Mori Y. Artificial intelligence in colonoscopy: A review on the current status. DEN open. Apr 2022;2(1):e109. doi: 10.1002/deo2.109.

12. Gupta N et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. May 2012;75(5):1022-30. doi: 10.1016/j.gie.2012.01.020.

13. Rex DK et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2011;73(3):419-22. doi: 10.1016/j.gie.2011.01.023.

14. Abu Dayyeh BK et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. Mar 2015;81(3):502.e1-16. doi: 10.1016/j.gie.2014.12.022.

15. Mori Y et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: A prospective study. Ann Intern Med. Sep 18 2018;169(6):357-66. doi: 10.7326/M18-0249.

16. Hassan C et al.. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. Oct 2010;8(10):865-9, 869.e1-3. doi: 10.1016/j.cgh.2010.05.018.

17. Hassan C et al. Artificial intelligence allows leaving-in-situ colorectal polyps. Clin Gastroenterol Hepatol. Nov 2022;20(11):2505-13.e4. doi: 10.1016/j.cgh.2022.04.045.

18. Areia M et al. Cost-effectiveness of artificial intelligence for screening colonoscopy: a modelling study. Lancet Digit Health. 06 2022;4(6):e436-44. doi: 10.1016/S2589-7500(22)00042-5.

19. Schottinger JE et al. Association of physician adenoma detection rates with postcolonoscopy colorectal cancer. JAMA. 2022 Jun 7;327(21):2114-22. doi: 10.1001/jama.2022.6644.

20. Oslo Uo. Optimising colorectal cancer prevention through personalised treatment with artificial intelligence. 2022.

21. Wadhwa V et al. Physician sentiment toward artificial intelligence (AI) in colonoscopic practice: a survey of US gastroenterologists. Endosc Int Open. Oct 2020;8(10):E1379-84. doi: 10.1055/a-1223-1926.

22. Kader R et al. Survey on the perceptions of UK gastroenterologists and endoscopists to artificial intelligence. Frontline Gastroenterol. 2022;13(5):423-9. doi: 10.1136/flgastro-2021-101994.

23. Rex DKet al. Artificial intelligence improves detection at colonoscopy: Why aren’t we all already using it? Gastroenterology. 07 2022;163(1):35-7. doi: 10.1053/j.gastro.2022.04.042.

24. Ahmad OF et al. Establishing key research questions for the implementation of artificial intelligence in colonoscopy: A modified Delphi method. Endoscopy. 09 2021;53(9):893-901. doi: 10.1055/a-1306-7590

Gastroenterology

October 2022

Cryer B et al. Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology. Gastroenterology. 2022 Oct;163(4):800-5. doi: 10.1053/j.gastro.2022.08.037. PMID: 36137708.



Bajaj JS and Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology. 2022 Oct;163(4):840-51. doi: 10.1053/j.gastro.2022.05.031. Epub 2022 May 19. PMID: 35598629; PMCID: PMC9509416.



November 2022

Grunvald E et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.



December 2022

Blackett JW et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology. 2022 Dec;163(6):1582-92.e2. doi: 10.1053/j.gastro.2022.08.034. Epub 2022 Aug 19. PMID: 35995074; PMCID: PMC9691522.



de Voogd F et al. Intestinal Ultrasound Is Accurate to Determine Endoscopic Response and Remission in Patients With Moderate to Severe Ulcerative Colitis: A Longitudinal Prospective Cohort Study. Gastroenterology. 2022 Dec;163(6):1569-81. doi: 10.1053/j.gastro.2022.08.038. Epub 2022 Aug 24. PMID: 36030056.
 

Clinical Gastroenterology and Hepatology

October 2022

Bhavsar-Burke I et al. How to Promote Professional Identity Development and Support Fellows-In-Training Through Teaching, Coaching, Mentorship, and Sponsorship. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2166-9. doi: 10.1016/j.cgh.2022.05.043. Epub 2022 Aug 7. PMID: 35948073.



van Megen F et al. A Low FODMAP Diet Reduces Symptoms in Treated Celiac Patients With Ongoing Symptoms – A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2258-66.e3. doi: 10.1016/j.cgh.2022.01.011. Epub 2022 Jan 17. PMID: 35051648.



November 2022

Sharzehi K et al. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20(11):2435-43.e4. doi: 10.1016/j.cgh.2022.05.054. Epub 2022 Jul 13. PMID: 35842117.



December 2022

Kardashian A et al. Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2790-9.e4. doi: 10.1016/j.cgh.2021.11.029. Epub 2021 Dec 16. PMID: 34958747.



Schuitenmaker JM et al. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2753-62.e2. doi: 10.1016/j.cgh.2022.02.058. Epub 2022 Mar 14. PMID: 35301135.
 

Techniques and Innovations in Gastrointestinal Endoscopy

Azizian JM et al. Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer. Tech Innov Gastrointest Endosc. 2022;24(3):254-61. doi: 10.1016/j.tige.2022.04.001. Epub 2022 Apr 18. PMID: 36540108; PMCID: PMC9762736.
 

Gastro Hep Advances

Kim RW et al. Timely Albumin Improves Survival in Patients With Cirrhosis on Diuretic Therapy Who Develop Acute Kidney Injury: Real-World Evidence in the United States. Gastro Hep Advances. 2023;2(2):252-60. doi: 10.1016/j.gastha.2022.10.008.

Gastroenterology

October 2022

Cryer B et al. Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology. Gastroenterology. 2022 Oct;163(4):800-5. doi: 10.1053/j.gastro.2022.08.037. PMID: 36137708.



Bajaj JS and Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology. 2022 Oct;163(4):840-51. doi: 10.1053/j.gastro.2022.05.031. Epub 2022 May 19. PMID: 35598629; PMCID: PMC9509416.



November 2022

Grunvald E et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.



December 2022

Blackett JW et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology. 2022 Dec;163(6):1582-92.e2. doi: 10.1053/j.gastro.2022.08.034. Epub 2022 Aug 19. PMID: 35995074; PMCID: PMC9691522.



de Voogd F et al. Intestinal Ultrasound Is Accurate to Determine Endoscopic Response and Remission in Patients With Moderate to Severe Ulcerative Colitis: A Longitudinal Prospective Cohort Study. Gastroenterology. 2022 Dec;163(6):1569-81. doi: 10.1053/j.gastro.2022.08.038. Epub 2022 Aug 24. PMID: 36030056.
 

Clinical Gastroenterology and Hepatology

October 2022

Bhavsar-Burke I et al. How to Promote Professional Identity Development and Support Fellows-In-Training Through Teaching, Coaching, Mentorship, and Sponsorship. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2166-9. doi: 10.1016/j.cgh.2022.05.043. Epub 2022 Aug 7. PMID: 35948073.



van Megen F et al. A Low FODMAP Diet Reduces Symptoms in Treated Celiac Patients With Ongoing Symptoms – A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2258-66.e3. doi: 10.1016/j.cgh.2022.01.011. Epub 2022 Jan 17. PMID: 35051648.



November 2022

Sharzehi K et al. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20(11):2435-43.e4. doi: 10.1016/j.cgh.2022.05.054. Epub 2022 Jul 13. PMID: 35842117.



December 2022

Kardashian A et al. Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2790-9.e4. doi: 10.1016/j.cgh.2021.11.029. Epub 2021 Dec 16. PMID: 34958747.



Schuitenmaker JM et al. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2753-62.e2. doi: 10.1016/j.cgh.2022.02.058. Epub 2022 Mar 14. PMID: 35301135.
 

Techniques and Innovations in Gastrointestinal Endoscopy

Azizian JM et al. Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer. Tech Innov Gastrointest Endosc. 2022;24(3):254-61. doi: 10.1016/j.tige.2022.04.001. Epub 2022 Apr 18. PMID: 36540108; PMCID: PMC9762736.
 

Gastro Hep Advances

Kim RW et al. Timely Albumin Improves Survival in Patients With Cirrhosis on Diuretic Therapy Who Develop Acute Kidney Injury: Real-World Evidence in the United States. Gastro Hep Advances. 2023;2(2):252-60. doi: 10.1016/j.gastha.2022.10.008.

Gastroenterology

October 2022

Cryer B et al. Bridging the Racial, Ethnic, and Gender Gap in Gastroenterology. Gastroenterology. 2022 Oct;163(4):800-5. doi: 10.1053/j.gastro.2022.08.037. PMID: 36137708.



Bajaj JS and Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology. 2022 Oct;163(4):840-51. doi: 10.1053/j.gastro.2022.05.031. Epub 2022 May 19. PMID: 35598629; PMCID: PMC9509416.



November 2022

Grunvald E et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.



December 2022

Blackett JW et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology. 2022 Dec;163(6):1582-92.e2. doi: 10.1053/j.gastro.2022.08.034. Epub 2022 Aug 19. PMID: 35995074; PMCID: PMC9691522.



de Voogd F et al. Intestinal Ultrasound Is Accurate to Determine Endoscopic Response and Remission in Patients With Moderate to Severe Ulcerative Colitis: A Longitudinal Prospective Cohort Study. Gastroenterology. 2022 Dec;163(6):1569-81. doi: 10.1053/j.gastro.2022.08.038. Epub 2022 Aug 24. PMID: 36030056.
 

Clinical Gastroenterology and Hepatology

October 2022

Bhavsar-Burke I et al. How to Promote Professional Identity Development and Support Fellows-In-Training Through Teaching, Coaching, Mentorship, and Sponsorship. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2166-9. doi: 10.1016/j.cgh.2022.05.043. Epub 2022 Aug 7. PMID: 35948073.



van Megen F et al. A Low FODMAP Diet Reduces Symptoms in Treated Celiac Patients With Ongoing Symptoms – A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2022 Oct;20(10):2258-66.e3. doi: 10.1016/j.cgh.2022.01.011. Epub 2022 Jan 17. PMID: 35051648.



November 2022

Sharzehi K et al. AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review. Clin Gastroenterol Hepatol. 2022 Nov;20(11):2435-43.e4. doi: 10.1016/j.cgh.2022.05.054. Epub 2022 Jul 13. PMID: 35842117.



December 2022

Kardashian A et al. Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2790-9.e4. doi: 10.1016/j.cgh.2021.11.029. Epub 2021 Dec 16. PMID: 34958747.



Schuitenmaker JM et al. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2753-62.e2. doi: 10.1016/j.cgh.2022.02.058. Epub 2022 Mar 14. PMID: 35301135.
 

Techniques and Innovations in Gastrointestinal Endoscopy

Azizian JM et al. Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer. Tech Innov Gastrointest Endosc. 2022;24(3):254-61. doi: 10.1016/j.tige.2022.04.001. Epub 2022 Apr 18. PMID: 36540108; PMCID: PMC9762736.
 

Gastro Hep Advances

Kim RW et al. Timely Albumin Improves Survival in Patients With Cirrhosis on Diuretic Therapy Who Develop Acute Kidney Injury: Real-World Evidence in the United States. Gastro Hep Advances. 2023;2(2):252-60. doi: 10.1016/j.gastha.2022.10.008.